Mersey Micro

Southport & Ormskirk Hospital NHS Trust

Build 2740

Install on your phone or tablet

Post Splenectomy Prophylaxis

Vaccines Antibiotics Other measures

Osteomyelitis

Specimen taking Acute Osteomyelitis Chronic Osteomyelitis

User's Manual

Mersey Micro is a digital version of Southport & Ormskirk Hospitals NHS Trust antibiotic policy.

This app is a product of Medicapps Ltd and is © 2013-2015 Southport & Ormskirk Hospitals NHS Trust. Liability for use of the app is with the Trust.

Mersey Micro was produced by Chris Seaton, Daniel Dryhurst, Elaine Hatch, Landi Elezi, Neil Darvill, Phil Corrin, Kevin Houghton, Rowan Pritchard Jones, and others.

How to install Mersey Micro

Mersey Micro is designed to work on iPads, but should also work well on modern desktop computers, iPhones, Android and Blackberry devices.

There is no need to install the app, and after the first time you use it on most devices it will then continue to work even if there is no network connection. If you are using an iPad or iPhone you will be prompted to choose to install the app as an icon on your home screen, but this is optional.

How to use Mersey Micro

Mersey Micro contains the complete text of the Trust's Antibiotic Policy document, and can be used as a simple reference document. Alongside the text, some protocols have been turned into interactive calculators to help you perform the calculations.

These policies reflect local antimicrobial susceptibility patterns and infection prevention issues and, unless otherwise stated, are intended for the treatment of immunocompetent adult patients. In addition, the antibiotic doses recommended are intended for adult patients with normal renal and liver function unless otherwise stated. For dosing in children, always refer to the BNF for Children (BNFC).

Where you see a 'Help me do the working out button' you can get an interactive version of the protocol. For example, this is the button next to the protocol for gentamicin. If you click it you will get an interactive version of the protocol that will help you work through the steps. You should only use this to help you work through the calculations - you must ensure that you are trained in, authorised to use, and thoroughly understand the protocol before you use it.

If you are in any doubt, do not use the calculator and instead seek advice.

How to report problems

In an emergency, contact the relevant department.

If you think there is a problem with the app or the calculators, report it to Southport & Ormskirk Hospitals NHS Trust IT via a support request.

Regulation

The Southport & Ormskirk Hospitals NHS Trust Antibiotic Guidance app is regulated in the UK by the MHRA.

How do we ensure that the calculators are correct?

We apply a system of multiple verification and validation checks to ensure that the calculators are correct.

  • The algorithms for the calculators are sourced from the original policy document, which has been produced and reviewed by clinicians in the Trust. This ensures the original algorithms are appropriate.

  • Trust clinicians have independently written test data and a verification implementation of the algorithms in a completely separate system. This ensures our interpretation of the policy is the same as the clinicians.

  • A large number of randomly generated test cases are also run against this verification implementation. This ensures that corner cases are explored.

  • Each time an app runs the same two sets of test data are run by the app itself and the app is not run if there is any discrepancy. This ensures that the implementation of that app matches the verification implementation, and that the web browser and underlying software and hardware is correctly executing the code.

Version History

Build 2734 - 09 November 2015

  • Final remaining fix and verification

Build 2733 - 21 October 2015

  • Amendments all made, ready for deployment to test environment for users to review

Build 2729 - 10 August 2015

  • Amendments all made, ready for deployment to test environment for users to review

Build 2724 - 03 July 2015

  • Release build for SOHT at level 2724

Endocarditis

Always discuss with a Microbiologist if endocarditis is suspected.

Take three sets of blood cultures at separate time intervals: 1 hour intervals are a minimum; ideally take samples at 6 hours apart (and if patient is clinically well await culture results). However, if the patient is acutely unwell or haemodynamically unstable, take the blood cultures at 15 minute intervals then start empirical antibiotics.

*Native valve, severe sepsis (or penicillin allergic):):
Vancomycin IV
AND
Gentamicin 1mg/kg IV 12 hourly (adjust in renal impairment)

Native valve, more indolent presentation:
Amoxicillin 2g IV 4 hourly
AND
Gentamicin 1mg/kg IV 12 hourly (adjust in renal impairment)

**Native valve, severe sepsis, with risk factors for multi-resistant gram negative infection:
Vancomycin IV
AND
Meropenem 2g IV 8 hourly

*Intracardiac prosthetic material (or MRSA suspected)
Vancomycin IV
AND
Rifampicin 300mg-600mg PO 12 hourly
AND
Gentamicin 1mg/kg IV 12 hourly (adjust in renal impairment)

If allergy to first line treatment options discuss with Microbiology

These are only initial empirical treatment guidelines. Treatment and duration of therapy will need to be reviewed according to species of organism isolated, antibiotic susceptibility of organism, patient risk factors, patient response and drug assays.


*Caution required with this combination of IV vancomycin and gentamicin as both agents are nephrotoxic and ototoxic. It is especially important to use the correct dose for the patient and to monitor levels appropriately. Monitor renal function daily and counsel the patient to report any hearing or balance issues. Target levels in endocarditis are:
Vancomycin: Pre-dose level must be 15-20mg/L
Gentamicin: Pre-dose level ≤ 1mg/L
Post-dose level 3-5mg/L

**Potential risk factors for multi-resistant gram negative infection include known colonisation with extended spectrum beta lactamase (ESBL) producing organisms or intravenous drug users.

For further guidance see also the BSAC guidelines for diagnosis and treatment of infective endocarditis in adults.

IV Line Infections

Remove line, send tip for culture (note: tips from lines removed routinely from patients with no evidence of infection must not be sent for culture) and send paired line and peripheral blood cultures.
Always inform infection prevention and control team.
Treatment must be reviewed in light of culture results.

Treatment:
Teicoplanin IV
AND
Gentamicin IV


If patient is immunocompromised see Neutropenic and Immunocompromised section

MRSA INFECTIONS

Important notes:

1. For empirical treatment where MRSA may be one of the causative pathogens but a definitive pathogen has not yet been confirmed, please refer to empirical treatment regimens given under the respective sections in these guidelines. Discuss treatment options with a Microbiologist if needed.
2. MRSA is always resistant to beta-lactam antibiotics (penicillin, flucloxacillin, co-amoxiclav (Augmentin®), piperacillin-tazobactam (Tazocin®), cephalosporins and meropenem)
3. Vancomycin must be given intravenously (oral vancomycin is not absorbed).
4. Vancomycin and gentamicin levels must be monitored.
5. Rifampicin and sodium fusidate should be given orally. If patient unable to tolerate oral treatment, please discuss with Microbiology. Please NOTE, these agents should not be used as montherapy as drug resistance can emerge rapidly.

For topical MRSA suppression therapy, please refer to Infection Control.

ACUTE PANCREATITIS


Antibiotics are usually NOT indicated. Fever is usually secondary to the inflammatory response and not an infectious process.

Refer to surgeons.

For severe cases e.g. organ failure, evidence of cholangitis or infected pancreatic necrosis, CRP >150, obesity (BMI >30):

First line treatment:

CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly
AND
A single dose of IV Gentamicin

If severe penicillin allergy:

Teicoplanin IV
AND

Ciprofloxacin 400mg IV 12 hourly
AND
Metronidazole 500mg IV 8 hourly

CHOLECYSTITIS/CHOLANGITIS/BILIARY SEPTICAEMIA


Specimen: Blood cultures, pus or aspirate (if available)
Infections of the biliary tract are often associated with bacteraemia or septicaemia. Always take cultures prior to starting antibiotic therapy.

First line treatment:

Co-Amoxiclav 1.2g IV 8 hourly
PLUS if patient has features of sepsis give:
A single dose of IV Gentamicin

If penicillin allergic:
Gentamicin IV
AND
Metronidazole 500mg IV 8 hourly

Duration of treatment: 5 days

Then if clinical condition permits (after 1-2 days IV antibiotics):
Switch to oral antibiotics according to blood culture isolate sensitivities OR if cultures and sensitivities are not available:

First line oral switch:

Co-amoxiclav 625mg PO 8 hourly

If penicillin allergy:
Co-trimoxazole 960mg PO 12 hourly
AND
Metronidazole 400mg PO 8 hourly

CLOSTRIDIUM DIFFICILE INFECTION


ISOLATE PATIENT - Contact Infection Prevention and Control for advice if needed
Refer to Southport and Ormskirk NHS Trust Clostridium difficile pathway

DIVERTICULITIS


First line treatment:

CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly
PLUS, if patient has features of sepsis, give:
A single dose of IV Gentamicin.

If severe penicillin allergy:
Gentamicin IV
AND
Metronidazole 500mg IV 8 hourly

Duration of treatment: 5 days

IV to oral switch guidance
Then if clinical condition permits (after 1-2 days IV antibiotics):
Switch to oral antibiotics according to isolate sensitivities OR if cultures and sensitivities are not available:

Co-trimoxazole 960mg PO 12 hourly
AND
Metronidazole 400mg PO 8 hourly

INTRA-ABDOMINAL ABSCESS


Surgical drainage is essential.
Antibiotic treatment as for peritonitis
Review treatment with culture and sensitivity results

LIVER ABSCESS


At least two sets of blood cultures must be taken before starting antibiotics.
Drainage is recommended for pyogenic liver abscess – send pus for microscopy and culture.

First line empirical treatment:

CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 400mg PO 8 hourly

Discuss with Microbiology if severe penicillin allergy.

Rationalise antibiotics according to culture results.
Duration: minimum 6 weeks (longer courses may be required dependent on extent of drainage, clinical progress including radiological improvement and whether multiple abscesses are present).

PERITONITIS


First line treatment:

CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly
AND
A single dose of IV Gentamicin

If severe penicillin allergy:

Teicoplanin IV
AND

Ciprofloxacin 400mg IV 12 hourly
AND
Metronidazole 500mg IV 8 hourly

Duration of treatment: 7 days

Protozoal infections


Amoebiasis
Metronidazole 800mg PO 8 hourly for 5 days (for intestinal infection) or 10 days (for extra intestinal infection) followed by paromomycin (unlicensed) 25-30 mg/kg in 3 divided doses for 7 days to eradicate cysts.

Giardiasis
Metronidazole 2g PO once daily for 3 days
OR
Metronidazole 400mg PO 8 hourly for 5 days

SPONTANEOUS BACTERIAL PERITONITIS


Pathogens: 60% Enterobacteriaceae
25% Gram positive organisms (mainly streptococci)
Specimens: Peritoneal fluid
Blood cultures

Refer the patient to the Gastroenterologists.

First line treatment:

CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly
AND
A single dose of IV Gentamicin (contact Pharmacy for dosing advice in patients with significant ascites)

Duration of treatment: 5 days

If severe penicillin allergy: discuss with Microbiology

IV to oral switch guidance:
If clinical condition permits:
Switch to oral antibiotics according to isolate sensitivities OR if cultures and sensitivities are not available:

Co-trimoxazole 960mg PO 12 hourly
AND
Metronidazole 400mg PO 8 hourly

Threadworm (Enterobius vermicularis)


Adults and children over 6 months: Mebendazole 100mg single dose orally
Children <6 months: Hygiene measures alone are advised.


Treat entire family (refer to GP)
Pregnant women should not be treated until post-partum.

• Hygiene measures Environmental hygiene measures — undertake on the first day of treatment:
  • Wash sleepwear, bed linen, towels, cuddly toys at normal temperatures and rinse well.
  • Thoroughly vacuum and dust, paying particular attention to the bedrooms, including vacuuming mattresses.
  • Thoroughly clean the bathroom by 'damp-dusting' surfaces, washing the cloth frequently in hot water.

  • • Strict personal hygiene measures — for 2 weeks if combined with drug treatment or for 6 weeks if used alone:
  • Wear close-fitting underpants or knickers at night. Change them every morning.
  • Cotton gloves may help prevent night-time scratching. Wash them daily.
  • Bath or shower immediately on rising each morning, washing around the anus to remove any eggs laid by the worms during the night.

  • • General personal hygiene measures — encourage all the time for all household members:
  • Wash hands and scrub under the nails first thing in the morning, after using the toilet or changing nappies, and before eating or preparing food.
  • Discourage nail biting and finger sucking.
  • Avoid the use of 'communal' or shared towels or flannels.
  • Typhoid fever


    Consult Microbiologist

    Campylobacter


    Most Campylobacter infections are self-limiting and antimicrobials are usually not required.
    If diarrhoea is very severe, very bloody or patient is febrile give:

    Clarithromycin 500mg PO 12 hourly for 5 days

    Ciprofloxacin should not be prescribed for Campylobacter infections unless the organism is proven sensitive as resistance levels are high.

    Salmonella


    Most Salmonella infections are self-limiting and antimicrobials are usually not required. Consult Microbiologist for advice.

    HELICOBACTER PYLORI - FIRST LINE


    Treatment should be offer to all positive patients with known duodenal or gastric ulcer or low grade MALToma.
    Duration of treatment for all regimes is 7 days (except for in MALToma where the treatment should be given for 14 days).
    Do not offer eradication for gastro-oesophageal reflux disease.
    Do not use clarithromycin, metronidazole or quinolone (e.g. levofloxacin) if used in the past year for ANY infection.
    It is usually preferable to wait until any other antibiotic courses have stopped before starting H. pylori eradication therapy.

    First line treatment:
    Lansoprazole 30mg PO 12 hourly
    AND
    Amoxicillin 1g PO 12 hourly
    AND
    Clarithromycin 500mg PO 12 hourly OR Metronidazole 400mg PO 12 hourly

    If patient is allergic to penicillin:
    Lansoprazole 30mg PO 12 hourly
    AND
    Metronidazole 400mg PO 12 hourly
    AND
    Clarithromycin 500mg PO 12 hourly

    If patient is penicillin allergic and has had previous exposure to clarithromycin:
    Lansoprazole 30mg PO 12 hourly
    AND
    Tripotassium dicitratobismuthate PO 240mg 12 hourly
    AND
    Metronidazole PO 400mg 12 hourly
    AND
    Tetracycline hydrochloride PO 500mg 6 hourly

    See also current Public Health England Guidance

    HELICOBACTER PYLORI - SECOND LINE

    Second line treatment – if symptoms still remain after first line treatment
    Lansoprazole 30mg PO 12 hourly
    AND
    Amoxicillin 1g PO 12 hourly
    AND
    Clarithromycin 500mg PO 12 hourly OR Metronidazole PO 400mg 12 hourly (which ever was not used during first line treatment)

    If patient has had previous exposure to both clarithromycin and metronidazole:
    Lansoprazole 30mg PO 12 hourly
    AND
    Amoxicillin 1g PO 12 hourly
    AND
    Tetracycline hydrochloride PO 500mg 6 hourly OR Levofloxacin PO 250mg 12 hourly

    If patient is penicillin allergic but not had previous exposure to a quinolone:
    Lansoprazole 30mg PO 12 hourly
    AND
    Metronidazole PO 400mg PO 12 hourly
    AND

    Levofloxacin PO 250mg 12 hourly

    If patient is penicillin allergic and has had previous exposure to a quinolone:
    Lansoprazole 30mg PO 12 hourly
    AND
    Tripotassium dicitratobismuthate PO 240mg 12 hourly
    AND
    Metronidazole PO 400mg 12 hourly
    AND
    Tetracycline hydrochloride PO 500mg 6 hourly

    See also current Public Health England Guidance

    ANTIBIOTIC PROPHYLAXIS FOR SURGERY / ENDOSCOPIC PROCEDURES


    Duration of prophylaxis
    Where single dose regimes are recommended these have been shown to be as effective as multiple dose regimes.
    The recommended number of doses should not be exceeded as this confers no advantage and is associated with greater toxicity, more adverse effects, more bacterial resistance and increased costs.
    Prophylaxis must be given within 1 hour before the procedure or surgical incision.
    The exceptions to single dose prophylaxis are stated below.
    In addition, if the operation lasts more than 4 hours and/or the total blood loss is >1500ml, further doses may be required.

    Operation Common Pathogens
    Not Penicillin/ Cephalosporin allergic
    Alternative regimens (allergy or high C. difficile risk)
           
    High leg amputation Clostridia CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg at induction
    Gentamicin IV 120mg at induction
    AND
    Metronidazole IV 500mg
    Biliary Tract Coliforms
    Anaerobes
    CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg at induction
    Gentamicin IV 120mg at induction
    AND
    Metronidazole IV 500mg
    Colorectal Surgery Coliforms
    Anaerobes
    First Line: CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg at induction. A subsequent dose should be given if the operation exceeds 5 hours
    Gentamicin IV 120mg
    AND
    Metronidazole IV 500mg at induction
    Appendicectomy Coliforms
    Anaerobes
    CefUROXime 1.5g IV
    AND
    Metronidazole 500mg IV at induction
    Gentamicin IV 120mg
    AND
    Metronidazole IV 500mg at induction
    Vascular Surgery Staph aureus
    Coliforms
    CefUROXime 1.5g IV at induction.
    If diabetic or gangrenous: Add Metronidazole IV 500mg at induction
    Gentamicin IV 5mg/kg at induction
    If diabetic or gangrenous: Add Metronidazole IV 500mg at induction
    Prosthetic Joint Surgery (Elective) Staphylococci
    Streptococci
    Coliforms
    CefUROXime IV 1.5g at induction.
    Give ONE additional dose at 8 hours if procedure >2 hours
    Teicoplanin 800mg IV
    AND
    Gentamicin IV 2mg/kg at induction
    Prosthetic Joint Surgery (Trauma) Staphylococci
    Streptococci
    Coliforms
    CefUROXime IV 1.5g at induction.
    +/- Teicoplanin IV 800mg based on risk assessment
    Teicoplanin 800mg IV
    AND
    Gentamicin IV 2mg/kg at induction
    TURP or Retropubic Prostatectomy (Millins or radical) Coliforms Rule out pre-op bacteriuria. Gentamicin IV 160mg on induction or according to culture results.
    Implantation of Urology Prosthesis Coliforms Co-amoxiclav IV 1.2g on induction
    OR
    CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg
    Gentamicin IV 160mg
    AND
    Metronidazole IV 500mg
    Transrectal prostate biopsy Coliforms Gentamicin 2mg/kg IV at induction.
    Followed by:Ciprofloxacin 500mg 12 hourly for up to 3 days for prolonged procedures/major blood loss.

    Check previous urine microbiology for gentamicin / ciprofloxacin resistant organisms and discuss with Microbiology if required.
    Cystectomy with Ileal Conduit Diversion Coliforms
    Anaerobes
    CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg
    Gentamicin IV 160mg
    AND
    Metronidazole IV 500mg at induction
    Caesarean Section   CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg prior to incision
    Gentamicin IV 120mg
    AND
    Clindamycin IV 600mg prior to incision
    Vaginal Hysterectomy   CefUROXime IV 1.5g
    AND
    Metronidazole IV 500mg at induction
    Gentamicin IV 120mg
    AND
    Clindamycin IV 600mg
    ERCP Coliforms Ciprofloxacin PO 750mg 60 – 90 minutes before procedures
    OR
    Gentamicin IV 120mg just before procedures
    OR
    Ciprofloxacin IV 400mg just before procedures
    PEG Coliforms CefUROXime IV 1.5g given 30 minutes prior to induction Gentamicin IV 160mg IV on induction


    N.B. MRSA Colonised patients: It is recommended that patients who are MRSA colonised should receive MRSA-colonisation eradication therapy ideally prior to surgery and should receive Teicoplanin IV 800mg stat at induction PLUS routine antibiotics.

    For patients known to be colonised with either; Extended-Spectrum Beta-Lactamase producing coliforms (ESBLs), Carbapenemase-Producing Enterobacteriaceae (CPEs), or Vancomycin Resistant Enterococci (VRE), please discuss appropriate surgical prophylaxis with Microbiology.

    ANTIBIOTIC PROPHYLAXIS OF INFECTIVE ENDOCARDITIS


    Antibiotics used to be offered routinely as a preventative measure to people at risk of infective endocarditis who were undergoing interventional procedures. Antibiotic prophylaxis has not been proven to be effective and there is no clear association between episodes of infective endocarditis and interventional procedures. Any benefits from prophylaxis need to be weighed against the risks of adverse effects for the patient and of antibiotic resistance developing. NICE (March 2008) recommended that antibiotic prophylaxis is no longer offered routinely for defined interventional procedures.

    Adults and Children with Structural Cardiac Conditions
    Regard people with the following cardiac conditions as being at risk of developing infective endocarditis
    • Acquired valvular heart disease with stenosis or regurgitation
    • Valve replacement
    • Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
    • Hypertrophic cardiomyopathy
    • Previous infective endocarditis

    Advice
    Offer people at risk of infective endocarditis clear and consistent information about prevention including:
    • The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended
    • The importance of maintaining good oral health
    • Symptoms that may indicate infective endocarditis and when to seek expert advice
    • The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing

    When to NOT offer prophylaxis
    Do not offer antibiotic prophylaxis against infective endocarditis:

    To people undergoing dental procedures
    To people undergoing non-dental procedures at the following sites:
  • Upper and lower gastrointestinal tract
  • Genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth
  • Upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy

  • Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people at risk undergoing dental procedures

    Considering Prophylaxis and Managing Infection
    • Investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce the risk of endocarditis developing
    • Offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection
    • Consult with a Cardiologist in individual cases where prophylaxis may be deemed necessary
    • Refer to NICE guidelines (2008) for appropriate antibiotic regimen if required

    PREVENTION OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)


    Patients with a history of one episode of spontaneous bacterial peritonitis should receive secondary prophylaxis with:

    Ciprofloxacin PO 500mg once daily (or 400mg once daily IV only if unable to tolerate oral).

    This should be continued lifelong until:
  • a) the patient undergoes liver transplantation
  • b) their liver disease improves/ascites resolves OR
  • c) isolation of an organism resistant to ciprofloxacin

  • NB: Long term use of ciprofloxacin (as with any other antibiotic) is likely to lead to selection of resistant organisms including C difficile. Ensure previous positive microbiology results are reviewed before ciprofloxacin is commenced. Patients with a history of ciprofloxacin resistant organisms (including those with a past history of C difficile infection) should be discussed with Microbiology before long term prophylaxis is commenced.


    Patients with cirrhosis and upper GI bleed
  • Patients with advanced cirrhosis and upper gastrointestinal haemorrhage e.g. bleeding oesophageal varices are at risk of developing SBP. These patients should receive primary prophylaxis against SBP for 5 days only as stated below.


  • First line:
    Piperacillin-tazobactam 4.5g IV 8 hourly
    AND
    A single dose of IV Gentamicin if patient has signs of sepsis/severe sepsis or septic shock (contact Pharmacy for dosing advice in patients with significant ascites)

    If patient has had recent treatment with co-amoxiclav or cefuroxime or if non-severe penicillin allergy:

    CeftRIAXone 2g IV 12 hourly

    If severe penicillin allergy:

    Ciprofloxacin 400mg IV or 500mg PO 12 hourly

    HUMAN BITES


    Topical cleansing, irrigation and debridement as indicated. Take blood cultures if IV treatment is indicated.
    Prescribe antibiotics for all human bites under 72 hours old, even if there is no sign of infection. If a bite is ≥72 hours old and there are no signs of infection, risk of infection is likely to be low and antibiotics are not indicated. If the bite is ≥72 hours old and there are clinical signs of infection, treat as below.

    First line (if patient able to have oral treatment):

    Co-amoxiclav 625mg PO 8 hourly for 5 days

    If penicillin allergic:
    Doxycycline 200mg PO 12 hourly for 2 doses then 200mg once daily
    AND
    Metronidazole 400mg PO 8 hourly
    N.B. Doxycycline must not be used in children under 12y or in pregnant /breast feeding women

    If IV treatment indicated:

    Co-amoxiclav 1.2g IV 8 hourly

    If IV treatment indicated and patient has non-severe penicillin allergy:

    CefUROXime 1.5g IV 8 hourly
    AND
    Metronidazole 500mg IV 8 hourly

    If IV treatment indicated and patient has severe penicillin allergy, discuss with Microbiology.

    In addition review if:
    Is tetanus immunisation up-to-date?
    Is Hepatitis B immunoglobulin/vaccine required?
    Consult Microbiologist if advice is required

    ANIMAL BITES


    Topical cleansing, irrigation and debridement as indicated. Take blood cultures if IV treatment is indicated.

    If infected - first line treatment:

    Co-amoxiclav 625mg PO 8 hourly for 5 days

    If penicillin allergic:
    Doxycycline 200mg PO 12 hourly for 2 doses then 200mg once daily
    AND
    Metronidazole 400mg PO 8 hourly
    N.B. Doxycycline must never be used in children under 12y or in pregnant/breast feeding women

    If patient is to be admitted and IV treatment is indicated

    Co-Amoxiclav 1.2g IV 8 hourly

    If IV treatment indicated and patient has a non-severe penicillin allergy

    CefUROXime IV 1.5g 8 hourly
    AND
    Metronidazole IV 500mg 8 hourly

    If IV treatment indicated and patient has severe penicillin allergy, discuss with Microbiology

    If not infected and presenting within 48 hours of injury give antibiotics as for infected bites ONLY IF high risk of infection as below
  • All cat bites
  • Animal bites to the hand, foot, face or genitalia
  • Puncture wounds
  • Bites requiring surgical debridement
  • Bites involving joints, tendons, ligaments or suspected fractures
  • Wounds that have undergone primary closure
  • Patients with diabetes, liver cirrhosis, asplenia or immunosuppression
  • Patients with a prosthetic valve or a prosthetic joint.

  • In addition review if:
  • Tetanus immunisation is up-to-date
  • There is a risk of rabies
  • Consult with Microbiologist if advice is required.
  • DISCITIS / VERTEBRAL ABSCESS


    It is preferable to discuss overall management of cases with the Neurosurgical team and antibiotic treatment with a Microbiologist.
    A minimum of 2 sets of blood cultures from separate sites within a 24 hour period should be taken prior to starting antibiotics but do not delay treatment if the patient is unwell. Discuss imaging results with the Radiologist as this may enable aspiration of pus for culture. Use culture and sensitivity reports to guide ongoing antibiotic treatment.

    For antibiotic treatment options see acute osteomyelitis

    INFECTED JOINT PROSTHESIS


    Take blood cultures and joint aspirate. Request an urgent Gram film.

    Attempted salvage of prosthesis may prove possible in the event of short-term clinical manifestation of infection.

    Attempts to salvage a stable prosthetic implant under such circumstances may involve:
    Aggressive surgical debridement/drainage of collection of pus – send multiple (at least 4 to 5) pus/tissue/fluid specimens taken at the time of operation (each taken with separate instruments).

    Antibiotics should be given according to culture and sensitivity results:
  • Intravenously for 2 weeks
  • Then orally for 3-6 months
  • Definitive antibiotic choice depends on culture results – liaise with Microbiology.

  • Chronic infections are often associated with sinus formation and signs of systemic sepsis are often not present. Organisms isolated from a sinus swab are not necessarily predictive of deep isolates. Bacteria may not be present in joint aspirate as they may be sequestered in biofilm.

    If patient is showing signs of systemic sepsis or acute infection is suspected do not delay antibiotic therapy whilst awaiting culture results:
    Teicoplanin IV
    AND
    Gentamicin IV

    If gentamicin is contraindicated discuss with Microbiology

    Culture results must guide subsequent therapy. Gentamicin should be discontinued if Gram negative bacteria are NOT isolated.

    For two stage revision
    Stage 1: Removal of infected implant (and send specimens for microscopy and culture as detailed above).
  • Insert antimicrobial spacer e.g. gentamicin plus additional appropriate
  • Antibiotic and/or drainage-irrigation systems (with or without appropriate antibiotic).
  • Antibiotics for 6 weeks according to culture results – liaise with Microbiology.

  • Stage 2: Implant new prosthesis if patient has clinically improved.
  • Send further tissue/fluid specimens (at least 4 to 5 taken at the time of operation to exclude on going infection).

  • NB.
    Antibiotics should be stopped at least 10 to 14 days before second stage surgery is performed in order to maximise the possibility isolating organisms from the intra-operative specimens in case there is still on-going infection at the surgical site.

    PREVENTION OF INFECTION IN PATIENTS WITH FRACTURES


    Lower limb open fracture (Gustilo type I)

    CefUROXime 1.5g IV as soon as possible after injury.
    Then 750mg 8 hourly until 24 hours after wound closure or for a maximum of 72 hours (whichever is sooner).

    If patient has severe penicillin allergy:

    Clindamycin 600mg IV 6 hourly in place of cefUROXime.


    Lower limb open fracture (Gustilo types II and III)

    CefUROXime 1.5g IV 8 hourly starting as soon as possible after injury until soft tissue closure or for a maximum of 72 hours.


    In addition, at time of first debridement give:
    Gentamicin 2mg/kg (single dose)

    In addition, at time of skeletal stabilisation and definitive soft tissue closure give:
    Gentamicin 2mg/kg at time of induction
    AND
    Teicoplanin 800mg IV at time of induction

    If patient has severe penicillin allergy:

    Clindamycin 600mg IV 6 hourly in place of cefUROXime.


    Open reduction of closed fracture with internal fixation

    CefUROXime 1.5g IV at induction (single dose).
    If history of MRSA ADD teicoplanin 800mg IV at induction to the above.

    Additional doses of cefUROXime 750mg at 8 and 16 hours only for prolonged procedures (lasting >4 hours) or if there is major blood loss (>1500ml).

    ADD Metronidazole 500mg IV 8 hourly to the above regimens if grossly contaminated

    CANDIDIASIS


    Oral:
    Nystatin oral suspension 1ml (100,000 units) PO 6 hourly
    Oral lesions in immunocompromised patients or those not responding to the above: Fluconazole 50mg PO daily for 7-14 days

    Oesophageal:
    Fluconazole 50mg PO daily for 14 days.
    Deep lesions not responding to oral therapy may require parenteral fluconazole.

    Intestinal:
    Nystatin oral suspension 5 mls (500,000 units) PO 6 hourly.

    Vaginal:
    See Obstetrics and Gynaecology Antimicrobial Guidelines

    Skin:
    1% Clotrimazole cream applied 2-3 times daily for 14 days.

    Systemic candidiasis:
    Consult Microbiologist for advice.

    ACUTE PROSTATITIS


    Send first void urine for culture and blood cultures.
    If sexually transmitted infection is suspected also send the following: urethral swab for gonococcal culture plus first void urine and/or urethral swab in Aptima transport medium for chlamydia and Neisseria gonorrhoeae PCR. Refer to Urologists.

    If oral treatment indicated

    Ciprofloxacin 500mg PO 12 hourly
    Treat for 4 weeks.

    If patient is systemically unwell ADD single dose of Gentamicin IV

    BALANITIS


    Usually due to candida species. Take swab.
    Topical 1% clotrimazole cream applied 2-3 times daily for 14 days or until symptoms settle

    CHLAMYDIA


    Note: the following regimes apply only when gonococcal infection has been excluded.

    Uncomplicated
    Doxycycline 100mg PO 12 hourly for 7 days (not in pregnancy or children under 12 years or breast feeding women).
    OR
    Azithromycin 1gm PO in a single dose (use this if poor compliance likely)

    Uncomplicated but pregnant/risk of pregnancy or breast feeding
    Azithromycin 1gm PO in a single dose
    Test for cure 6 weeks after treatment due to lower cure rate in pregnancy

    Upper genital infection (female, pelvic inflammatory disease)
    Refer to pelvic inflammatory disease (PID) treatment guidance.

    Upper genital infection (male)
    Doxycycline 100mg PO 12 hourly for 14 days
    OR

    Ofloxacin 200mg PO 12 hourly for 14 days

    Consult Sexual Health Clinic for advice on screening for other sexually transmitted infections and contact tracing of sexual partners.

    EPIDIDYMO-ORCHITIS


    Send first void urine for culture stating which antibiotic is to be started.
    If sexually transmitted infection is suspected also send the following: urethral swab for gonococcal culture plus first void urine and/or urethral swab in Aptima transport medium for chlamydia and Neisseria gonorrhoeae PCR.

    ≤ 35 y
    Likely pathogens: Neisseria gonorrhoeae, Chlamydia trachomatis

    CefTRIAXone 500mg stat intramuscularly
    AND
    Doxycycline 100mg PO 12 hourly for 14 days
    If severely penicillin allergic contact Microbiology for advice
    Referral to Integrated Sexual Health Service is essential (01704 513303).

    > 35 y
    Likely pathogens: Enterobacteriaceae

    Ciprofloxacin 500mg PO 12 hourly for 2 weeks

    If patient is systemically unwell ADD single dose of Gentamicin IV

    NEISSERIA GONORRHOEAE


    Uncomplicated

    CefTRIAXone 500 mg intramuscularly as a single dose
    AND
    Azithromycin 1 g PO as a single dose

    Upper genital infection (female, PID)
    Refer to pelvic inflammatory disease (PID) treatment guidance.

    Upper genital infection (male)
    Treat as per epididymo-orchitis regimen

    Consult Sexual Health Clinic for advice on screening for other sexually transmitted infections and contact tracing of sexual partners.

    GENERAL GUIDANCE


    Note: Ciprofloxacin should only be used when patient is known to be infected with Pseudomonas. This antibiotic has no activity against pneumococci (the most common respiratory pathogen). The following antibiotic regimes refer to empirical treatment – review previous microbiology results prior to prescribing antibiotics. Ensure appropriate specimens are sent before antibiotic therapy if possible and rationalise empirical treatment based on results.

    ASPIRATION PNEUMONIA



    First line treatment:

    CefUROXime 1.5g IV 8 hourly
    AND
    Metronidazole 500mg IV 8 hourly

    If severe penicillin allergy:

    Levofloxacin 500mg IV 12 hourly
    AND
    Metronidazole 500mg IV 8 hourly

    If history of MRSA, ADD Teicoplanin IV to above treatment

    When ready for oral treatment, review positive microbiology. If none available, change to:

    First line IV to oral switch treatment:

    Co-Amoxiclav 625mg PO 8 hourly

    If penicillin allergic:

    Levofloxacin 500mg PO 12 hourly
    AND
    Metronidazole 400mg PO 8 hourly

    If history of MRSA: Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily
    AND
    Metronidazole PO 400mg 8 hourly

    Duration: Treat for 5 – 10 days

    ATYPICAL PNEUMONIA (known pathogen)


    Pneumocystis jirovecii (carinii)
    Risk factors: immunocompromised e.g. HIV/chemotherapy
    Specimens: PCR on induced sputum or BAL fluid (ordinary sputum is a less optimal specimen).
    No serological test available. PCR on EDTA blood can be considered if unable to obtain any respiratory specimens.
    Treatment:
    Co-trimoxazole (high dose) IV or orally, depending on condition, 120mg/kg daily to be given in 2-4 divided doses for at least 3 weeks. A dosing table is provided in the ward drug files (orange folders) to assist correct dosing.
    If signs of bone marrow depression occur, give calcium folinate 15mg/day supplementation
    Adjunctive corticosteroid therapy can be life-saving in severe cases.

    Legionella
    Specimens: Urine (in white top sterile universal container) for legionella antigen (rapid test)
    Sputum for legionella culture (NB. this must be specifically stated on the request card)
    Serological testing is no longer recommended.
    Treatment:

    Levofloxacin IV 500mg 12 hourly

    Switch to oral Levofloxacin 500mg 12 hourly when response to treatment.

    Duration:
    14 days (immunocompetent)
    14 – 21 days (immunocompromised)

    Mycoplasma
    Specimens:Serology
    Treatment:
    Clarithromycin 500mg IV 12 hourly if ill
    OR
    Clarithromycin 500mg PO 12 hourly if clinical condition permits.
    Duration: 10-14 days

    Chlamydia psittaci (psittacosis)/Chlamydia pneumoniae
    Specimens: Serology
    Treatment:
    Doxycycline PO 200mg twice daily for 2 doses then 200mg once daily
    OR
    Clarithromycin 500mg IV 12 hourly
    Duration: 14-21 days

    EMPYEMA AND LUNG ABSCESS


    Drainage is important – send fluid for culture before starting antibiotics if possible as well as blood cultures.

    First line treatment:
    Piperacillin-tazobactam 4.5g IV 8 hourly

    If penicillin allergic:
    Teicoplanin IV
    AND
    Aztreonam 1g IV 8 hourly
    AND
    Metronidazole 500mg IV 8 hourly

    Discuss duration of therapy with Microbiology

    EXACERBATION OF COPD (Chronic Obstructive Pulmonary Disease)


    Antibiotics are indicated for an exacerbation associated with a history of more purulent sputum.
    In selecting an antibiotic, recent positive sputum results and antibiotic therapy should be taken into account.

    Remember: Between 20-40% of COPD exacerbations are of non-infective aetiology.
    Up to 30% of infective exacerbations are viral in origin.
    Obtain sputum for culture if possible BEFORE starting antibiotics.

    If oral therapy is indicated
    First line oral treatment:
    Amoxicillin 500mg – 1g PO 8 hourly for 5 days

    If penicillin allergic or history of MRSA:
    *Doxycycline PO 200mg 12 hourly for 2 doses then 200mg every 24 hours for 5 days

    *Patients in emergency department with mild infection and not for admission may be prescribed the typical primary care dose of 200mg on first day then 100mg once daily.


    If IV therapy is indicated
    First line IV treatment:
    Amoxicillin 1g IV 8 hourly
    OR

    Co-amoxiclav IV 1.2g 8 hourly should be considered in non-penicillin allergic patients with more severe disease or those who have been recently treated with amoxicillin / clarithromycin / erythromycin.

    If history of MRSA or penicillin allergic and IV treatment required:

    Teicoplanin IV AND Ciprofloxacin 400mg IV 12 hourly

    IV to oral switch guidance:
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg every 24 hours

    HOSPITAL ACQUIRED PNEUMONIA


    (> 48 hours after admission or presenting within 10 days of last discharge from hospital)
    Treatment should be based on recent sputum cultures where available. Duration of treatment 5-10 days

    PATIENTS NOT ON ICU
    Choose antibiotic from the following list (in order), avoiding antibiotics that the patient has recently been treated with. Severe hospital acquired pneumonia is characterised by:

    General Admission to ICU. New mental confusion
    Chest X-Ray
    Bilateral or multi-lobular shadowing or rapidly progressive lung infiltrates.
    Respiratory failure Respiratory rate ≥ 30/min
    Hypoxia (PaO2 < 8kPa or SaO2 < 92% on any FiO2)
    Need for > 35% oxygen to maintain arterial oxygen saturation > 90%
    Need for ventilatory support
    Evidence of severe sepsis
    Shock (systolic BP < 90mmHg or diastolic BP ≤ 60mmHg)

    Non-severe hospital acquired pneumonia (including patients known to be colonised with MRSA):
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily

    Severe hospital acquired pneumonia
    First line treatment:

    CefUROXime 1.5g IV 8 hourly
    If aspiration pneumonia suspected ADD metronidazole 500mg 8 hourly IV
    If recent therapy with cefUROXime discuss with Microbiology

    If severe penicillin allergy:

    Levofloxacin 500mg IV 12 hourly (switch to oral levofloxacin when condition permits)
    ADD Metronidazole 500mg IV 8 hourly if aspiration suspected.

    If history of MRSA, ADD Teicoplanin IV


    PATIENTS ON ICU
    For ICU patients who develop pneumonia prior to ventilation, please refer to the community or hospital acquired pneumonia guidance as appropriate. For patients who develop pneumonia after ventilation, refer to ventilator associated pneumonia guidance

    POST-INFLUENZA PNEUMONIA


    Staphylococcus aureus infection is more likely, consider MRSA colonisation

    First line treatment:

    Co-amoxiclav 1.2g IV 8 hourly

    IV to oral switch guidance:

    Co-amoxiclav 625mg PO 8 hourly

    Non-severe penicillin allergy:

    CefUROXime 1.5g IV 8 hourly

    IV to oral switch guidance:
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily

    If history of MRSA, ADD Teicoplanin IV to IV therapy above and use doxycycline for oral switch

    Severe penicillin allergy:

    Teicoplanin IV AND Ciprofloxacin 400mg IV 12 hourly

    IV to oral switch guidance:
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily

    TUBERCULOSIS (Notifiable)


    Discuss all known or suspected cases with Consultant Chest Physicians (based on the respiratory ward) and with the Infection Prevention and Control team.

    Note that this is a statutory notifiable infection.

    VENTILATOR ASSOCIATED PNEUMONIA


    Check recent laboratory reports. If none, first line treatment:

    CefUROXime 1.5g IV 8 hourly

    If patient has recently been treated with cefUROXime use:
    Piperacillin-tazobactam 4.5g IV 8 hourly (if not penicillin allergic)

    If patient has been recently treated with piperacillin-tazobactam or has resistant organisms use:
    Meropenem 1g IV 8 hourly

    If history of MRSA, ADD Teicoplanin IV to above treatment.

    In severe penicillin allergy:
    Linezolid 600mg IV 12 hourly
    AND
    Aztreonam 1g IV 8 hourly

    WHOOPING COUGH (Notifiable)

    Treatment and prophylaxis: Clarithromycin 500mg PO 12 hourly (for adults) for 7 days.
    Please see “BNF for Children” for paediatric doses.

    Prophylaxis: Household contacts where there are vulnerable children (e.g. unimmunised children, newborn, chronic illness, immunocompromised)
    This must be given within 21 days of onset of the primary case. Please liaise with Public Health England and see Guidelines for the Public Health Management of Pertussis

    MENINGITIS


    Pyrexia plus a rash should be treated as meningitis until proven otherwise.
    Inform Infection Prevention and Control and Public Health England immediately.

    Specimens
    CSF
    Blood cultures
    EDTA blood for meningococcal and pneumococcal PCR
    Nasopharyngeal swab for culture and sensitivity
    If viral aetiology is suspected send: throat swab for viral PCR in viral transport medium.

    Guidance on prophylaxis of contacts for Meningococcal and Haemophilus influenza type B meningitis will be provided by Public Health England and is discussed in the prophylaxis section of this guideline.

    EMPIRICAL TREATMENT
    First line treatment:

    CefTRIAXone 2g IV 12 hourly

      Additional Listeria cover is needed if patient is immunocompromised, pregnant, or aged >55 years:
    If patient has severe penicillin allergy:
    Chloramphenicol IV
    Please see BNF for adult doses; dose is usually around 1g IV 6 hourly.

      Additional Listeria cover is needed if patient is immunocompromised, pregnant, or aged >55 years:
    If recent travel abroad or other risk of penicillin resistant Pneumococci infection ADD IV Vancomycin to the above treatments

    Consider adding dexamethasone in line with current British Infection Association guidelines.

    If viral encephalitis is suspected see herpes simplex encephalitis section for guidance



    TREATMENT FOR KNOWN ORGANISM
    Meningococcal (Gram negative coccus)

    CefTRIAXone 2g 12 hourly IV
    OR
    Chloramphenicol IV (if severe penicillin allergy)
    Please see BNF for adult doses; dose is usually around 1g IV 6 hourly
    Duration: 7 days
    If patient did not receive treatment with cefTRIAXone, give a single dose of ciprofloxacin 500mg PO (adult dose) to clear nasopharyngeal carriage prior to discharge from hospital.

    Pneumococcus (Gram positive diplococcus)

    CefTRIAXone 2g 12 hourly IV
    OR
    Chloramphenicol IV (if severe penicillin allergy)
    Please see BNF for adult doses; dose is usually around 1g IV 6 hourly
    Duration:10-14 days

    Haemophilus influenzae type B or HiB (Gram negative coco-bacillus)

    CefTRIAXone 2g 12 hourly IV
    OR
    Chloramphenicol IV (if severe penicillin allergy)
    Please see BNF for adult doses; dose is usually around 1g IV 6 hourly
    Duration: 7-10 days
    In addition, also give 4 days PO rifampicin 600mg 12 hourly to clear nasopharyngeal carriage prior to discharge from hospital.
    Cases of HiB disease in under 10 years of age should be given HiB vaccine as well as rifampicin for 4 days to eradicate nasopharyngeal carriage before discharge from hospital. HiB disease occasionally fails to generate immunity, especially in the very young.

    Listeria monocytogenes (Gram positive bacillus)
    Amoxicillin 2g IV 4 hourly
    AND
    Gentamicin IV

    If non-severe penicillin allergy
    Meropenem 2g IV 8 hourly

    If severe penicillin allergy
    Co-trimoxazole IV 120mg/kg in 4 divided doses

    Duration: 2-3 weeks

    BRAIN ABSCESS


    Arrange an urgent CT scan by Radiology Department.
    Contact on call Neurosurgeon at The Walton Centre for Neurology and Neurosurgery.
    Tel: 0151 525 3611

    Empirical treatment:

    CefTRIAXone 2g IV 12 hourly
    AND
    Metronidazole 500mg IV 8 hourly

    An extended course will be required

    HERPES SIMPLEX ENCEPHALITIS


    Treat if clinically suspected
    Viral PCR testing is available on CSF specimen to aid diagnosis. Please request viral PCR testing on the request form or phone the microbiology laboratory.

    Give IV aciclovir 10mg/kg every 8 hours for 21 days.
    Dose must be adjusted in renal impairment.
    Use Adjusted Body Weight (ABW) in obese patients to avoid excessive dosing.

    First work out Ideal Body Weight for height:
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • Then use Ideal body Weight (IBW) and Total Body Weight (TBW) to work out ABW
  • ABW (kg) = IBW + 0.4(TBW – IBW)
  • MANAGEMENT OF IMMUNOCOMPROMISED HAEMATOLOGY PATIENTS


    Guidelines on the assessment and treatment of fever in patients with active haematological malignancy or neutropenia.

    Definitions

    Fever
  • 1. Temperature > 38°C on 2 occasions 1 hour apart
  • 2. Single temperature > 39°C

  • Antimicrobial therapy should be instituted if there are clinical signs of sepsis even in the absence of fever.
    N.B. Fever may be absent in some patients with infections (e.g. dehydrated, on antipyretics severely ‘shocked’ or taking steroids/NSAIDs). Conversely, other non-infective causes of fever must be considered.

    Immunocompromised
  • 1. Patients with active haematological malignancy, (e.g. undergoing treatment or not in remission) or on immunosuppressive therapy
  • 2. Neutropenia (Neutrophils < 0.5 x 109/L)
  • 3. Patients receiving cancer chemotherapy or within 3 months of completion of such therapy
  • The possibility of infection must be considered in any patient undergoing treatment for cancer who presents as “unwell” with or without fever, especially if also neutropenic. Do not delay administration of antibiotics whilst awaiting WCC results.



    Management
  • 1. Fever in an immunocompromised patient is a medical emergency
  • 2. Resuscitate patient
  • The time from the onset of fever to antibiotic administration is critical and should be minimised. It is preferable to take 2 sets of blood cultures immediately (paired set if patient has a Hickmann/PICC line), assess antibiotic allergy, and initiate antibiotics prior to full clinical assessment. This should be done within 1 hour of presentation.

    Examination of febrile neutropenic patients must include:

    Specific questions as to the presence of:
  • respiratory tract symptoms – nasal congestion, sore throat, cough, pleuritic chest pain, shortness of breath
  • painful ulcers/lesions in the groin/perineum
  • new rash, or new onset of diarrhoea
  • Full examination including skin & mucous membranes, as well as the perineum & peri-anal area
  • Fundoscopy can reveal systemic infection (e.g. Candida endophthalmitis)
  • Repeat reviews daily whilst the fever is ongoing

  • Repeat reviews daily whilst the fever is ongoing
    Investigate for cause of fever
  • FBC and film
  • U&E, LFTs, Bone, Clotting, trough Itraconazole levels if on prophylaxis
  • Hickman/PICC line cultures AND peripheral blood cultures (the first blood drawn through the central line should be cultured) and labelled appropriately
  • If no central line in-situ, take 2 independent peripheral blood cultures routinely
  • Exit or line site swabs if signs of infection
  • CXR
  • Sputum if pneumonia suspected, Pneumocystis (Carinii) jirovecii PCR if required by Consultant Haematologist
  • MSU
  • Stool sample if diarrhoea


  • Also consider – as clinically indicated
  • Atypical serology screen and urine for legionella antigen, if community acquired pneumonia suspected
  • Throat swab
  • Lumbar puncture
  • Broncho-alveolar lavage
  • ECHO
  • CT scan to look for collections
  • Any skin or soft tissue infection
  • EDTA blood for CMV PCR, Candida PCR, Aspergillus PCR


  • First Line Therapy
    Piperacillin/Tazobactam (Tazocin) IV 4.5g 6 hourly (four times a day)
    AND
    Consider Gentamicin IV as a single stat dose.
    Caution if patient has recently received platinum based chemotherapy or has Multiple Myeloma. A decision to continue with Gentamicin must be made on the Consultant post-take ward round.

    If non-severe penicillin allergy
    Meropenem IV 1g 8 hourly

    For patients with impaired renal function (serum creatinine > 165micromol/L) consider using Meropenem as 1st line.

    If severe penicillin allergy: Discuss with Microbiology

    Patients will require daily reviews and daily FBC

    Chest Infection
    For patients with community acquired pneumonia Clarithromycin IV 500mg 12 hourly should be routinely added

    Herpetic Lesions
    Add Aciclovir IV 10mg/kg body weight 8 hourly
    Adjust dose in renal impairment
    Use Adjusted Body Weight (ABW) in obese patients to avoid excessive dosing.

    First work out Ideal Body Weight for height (IBW):
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • Then use Ideal Body Weight (IBW) and Total Body Weight (TBW) to work out ABW:
  • ABW (kg) = IBW + 0.4(TBW – IBW)

  • Cellulitis at Central Line or Rigor with Flushing or MRSA colonised
    Add Teicoplanin IV. Do not use the line pending advice from Consultant Haematologist. Consider REMOVAL of line.

    Discuss with on-call Consultant Haematologist at Aintree University Hospitals NHS Foundation Trust Telephone 0151 525 5980

    MANAGEMENT OF INFECTION IN OTHER IMMUNOCOMPROMISED PATIENTS


    Please notes this section is NOT for the management of patients with haematological malignancies

    Examples of Immunocompromised Patients
  • Oncology patients receiving chemotherapy
  • Neutropenia (Neutrophils < 0.5 x 109/L)
  • HIV infection (CD4 < 500x106/L)
  • High dose steroids
  • Autoimmune disease
  • Severely malnourished patients

  • Sepsis
    Fever of 39°C on one occasion or 38°C on 2 occasions 1 hour apart

    Management:
    Resuscitate patient

    Investigate for cause of fever
  • No Central Line: 2 sets of blood cultures from different sites. No delay required between samples
  • Hickman/PICC Line: Take blood cultures through the central line (the first blood drawn through should be cultured) AND peripheral blood cultures
  • MSU but do not delay antibiotics until obtained
  • FBC, U&Es, LFTs, Bone, Clotting
  • Stool if diarrhoea
  • Line exit site swabs if signs of infection
  • Throat swab
  • CXR
  • 10mL for virus serology – ask for storage
  • Swab or specimen from any symptomatic site

  • Antibiotics:
    FOR ONCOLOGY PATIENTS: IF IN ANY DOUBT, IT IS BEST TO ASSUME NEUTROPENIC SEPSIS AND GIVE FIRST DOSE ANTIBIOTICS WITHIN 60 MINUTES AS PER CANCER SERVICES GUIDELINES. Southport & Ormskirk Hospital NHS Trust Cancer Services

    First line treatment:
    Piperacillin-tazobactam 4.5g IV 8 hourly and consider Gentamicin IV as a single stat dose

    If non-severe penicillin Allergy:
    Meropenem IV 1g 8 hourly

    If severe penicillin allergy discuss with Microbiology

    Suspected chest infection
    Add Clarithromycin IV 500mg 12 hourly

    Herpetic lesions:
    Add Aciclovir IV 10mg/kg body weight 8 hourly
    Adjust dose in renal impairment
    Use Adjusted Body Weight (ABW) in obese patients to avoid excessive dosing.
    First work out Ideal Body Weight for height (IBW):
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • Then use Ideal Body Weight (IBW) and Total Body Weight (TBW) to work out ABW:
  • ABW (kg) = IBW + 0.4(TBW – IBW)


  • Cellulitis at Central Line or Rigor with Flushing or MRSA colonised: Add Teicoplanin IV

    Please refer all septic cancer patients (neutropenic and non-neutropenic) to the ACUTE ONCOLOGY TEAM (Ext. 5237) as soon as possible.
    Specialist Oncology Nurse (First contact) ASCOM 3846 Mon-Fri 9am-5pm
    For advice out of hours contact Clatterbridge triage service on 0800 1695555

    SEPSIS SCREENING AND CARE BUNDLE - ADULTS


    The local Trust Adult Sepsis Screening Tool is shown below.

    CELLULITIS / ERYSIPELAS

    Always take a swab of lesions. Take blood cultures if IV treatment is indicated.


    In mild severity
    First line treatment:
    Flucloxacillin 500mg – 1g PO 6 hourly

    If penicillin allergic
    Clarithromycin 500mg PO 12 hourly
    OR
    If history of MRSA
    Doxycycline PO 200mg twice daily for 2 doses then 200mg once daily

    Duration 7 days



    If moderate to severe infection
    First line treatment:
    Flucloxacillin 2g IV 6 hourly

    If penicillin allergic OR history of MRSA
    Teicoplanin IV

    Duration 1-2 weeks

    For patients who may be suitable for outpatient IV antibiotic therapy refer to Trust OPAT policy (Clin Corp 93).

    IMPETIGO (Streptococcal or Staphylococcal)

    If localised
    Mupirocin ointment 2% topically 3 times a day for 5-7 days

    If widespread Flucloxacillin PO 500mg 6 hourly for 7 days

    OR if penicillin allergic
    Clarithromycin PO 500mg 12 hourly for 7 days

    LEG ULCERS AND PRESSURE SORES

    Avoid antibiotics
    Use local cleansing and topical antiseptics if required.
    Refer to tissue viability for wound care review
    If cellulitis/fever take blood cultures and swabs. Treat according to cellulitis guidance.

    NECROTISING FASCIITIS

    Early diagnosis can be difficult but marked systemic toxicity out of proportion to the local findings should alert the clinician. Early diagnosis and intervention is crucial.
    Necrotising fasciitis is a surgical emergency: surgery is the mainstay of treatment i.e. debridement of all infected/necrotic tissue.

    Specimens
    Blood cultures
    Tissue/pus/aspirate from subcutaneous tissue

    Antibiotic treatment:
    Always check previous positive microbiology results prior to starting antibiotics. The empirical regimes below cover most organisms however, if the patient has a history of multi-resistant organisms not covered by the antibiotics given below or antibiotic allergies, please discuss with a Microbiologist.


    First line treatment:
    Piperacillin-tazobactam 4.5g IV 6 hourly
    AND

    Clindamycin 1.2g IV 6 hourly


    Non-severe penicillin allergy:
    Meropenem 1g IV 8 hourly
    AND

    Clindamycin 1.2g IV 6 hourly


    Severe penicillin allergy – discuss with Microbiology

    Duration: 10-14 days

    Considerations in spinal injury patients

    Choice of antimicrobial agent(s) for infection in spinal injuries patients is essentially the same as for other adult patients and should be in accordance with the relevant section of the antimicrobial guidelines. However, given higher rates of antimicrobial resistance encountered in this specific patient population, it is especially important to always check recent surveillance samples for evidence of Gentamicin resistant coliforms, Extended Spectrum β Lactamase (ESBL) producers and other multi-resistant organisms.

    Ensure empirical antimicrobial therapy is appropriate. Consider substituting Amikacin 15mg/kg once daily (maximum 1g daily) for Gentamicin if there is evidence of Gentamicin resistant coliforms. Monitor levels.

    Seek further advice as necessary from the Consultant on-call or Consultant Microbiologist

    Antibiotic Prophylaxis in spinal injuries patients

    Clinical Diagnosis Treatment Advice Comments
         
    Neurosurgical Implants

    1 Baclofen pumps
    2 Phrenic pacer

    Cefuroxime IV 750mg-1.5g 8 hourly
    AND
    Teicoplanin IV 800mg daily
    AND
    Gentamicin IV 3mg/kg daily – monitor levels.
    Duration is 3 days
    Urinary catheter change Prophylaxis NOT required UNLESS patient has had a history of sepsis after previous catheter insertion/change or known history of difficult/traumatic catheterisation in the past.
    Gentamicin 160mg IM or IV stat
    Check urine culture for Gentamicin resistant organisms.

    Check when last dose of Gentamicin was administered and levels if applicable.

    Surveillance Specimens

    Ventilated patients should have routine surveillance sputum cultures taken weekly (usually Tuesdays). Patients with indwelling urinary catheters should have surveillance specimens if clinically indicated. Surveillance samples provide information on colonising organisms, and should ONLY be acted upon in patients with signs of sepsis. Asymptomatic patients should not be started on antimicrobial therapy as this will lead to multi-resistant organisms and increased risk of Clostridium difficile infection (CDI).

    Vaccinations

    Annual influenza vaccine should be offered to tetraplegic patients and pneumococcal vaccine (Pneumovax) should be offered to new tetraplegic admissions.

    CONJUNCTIVITIS (BACTERIAL)

    Discuss with an Ophthalmologist if severe.

    Specimen
    Eye swab for culture.

    First line therapy
    Chloramphenicol 1% eye ointment applied 3-4 times daily
    OR
    Chloramphenicol 0.5% eye drops applied every 2-3 hours for the first 48 hours then reduced to 6 hourly.

    NB A combination of eye drops during the day and eye ointment at night can be used. This avoids the blurred vision caused by ointment during the day and the need to disturb sleep while applying drops throughout the night.

    Duration
    48 hours after resolution

    EPIGLOTTITIS

    Please see Trust Paediatric Antimicrobial Guidelines for children. Epiglottitis usually occurs in young children – but rarely may occur in adults.

    This is a medical emergency - Critical Care review required
    Take blood cultures
    Beware trying to examine pharynx or taking throat swabs as respiratory obstruction may occur.

    First line treatment

    CefTRIAXone 2g IV 12 hourly

    If severe penicillin allergy
    Chloramphenicol IV
    Please see BNF for adult doses; dose is usually around 1g IV 6 hourly.

    PAROTITIS

    Take blood cultures and purulent drainage from Stensen’s duct (if present) for culture
    Ensure adequate hydration

    First line treatment
    Flucloxacillin IV 1g 6 hourly

    If penicillin allergic OR colonised with MRSA
    Teicoplanin IV

    When ready for oral treatment review positive microbiology. If none available change to:
    First line oral switch
    Flucloxacillin PO 500mg-1g QDS

    If penicillin allergic

    Clindamycin PO 300mg QDS

    If colonised with MRSA Doxycycline PO 200mg 12 hourly for 2 doses then 200mg every 24 hours

    Duration of treatment is 10-14 days in total

    SINUSITIS (acute)

    See the NICE guidance summary below on decision to prescribe. Click on the image to view the full guidance.



    If antibiotic treatment is warranted:

    Phenoxymethypenicillin PO 500mg every 6 hours for 5 days
    OR
    Clarithromycin PO 500mg every 12 hours for 5 days

    TONSILLITIS (streptococcal)

    See NICE guidance below on decision to prescribe an antibiotic. Click the image to view the full guidance.

    If antibiotic treatment is warranted:
    Take a throat swab.

    First line treatment:
    Phenoxymethylpenicillin (Penicillin V) PO 500mg every 6 hours for 5-10 days

    If penicillin allergic:
    Clarithromycin PO 500mg every 12 hours for 5 days

    NB. Most throat infections are caused by viruses.
    Await culture results of throat swabs if possible. Start treatment immediately after throat swab if patient is ill or has rheumatic heart disease.
    Avoid amoxicillin if possibility of glandular fever (Epstein Barr virus/EBV) due to increased risk of rash.

    SEVERE TONSILLAR PHARYNGITIS AND QUINSY

    Take blood sample (EDTA) for Paul Bunnell (Monospot) test.
    Take a throat swab.

    First line treatment
    Benzylpenicillin IV 1.2g 4 hourly
    If Quinsy ADD Metronidazole 500mg IV 8 hourly

    If penicillin allergic:

    Clindamycin IV 600mg 6 hourly

    IV to oral switch
    If clinical condition permits, after 1-2 days of IV antibiotics

    First line for oral switch:
    Phenoxymethylpenicillin (Penicillin V) 500mg PO 6 hourly

    If penicillin allergic:
    Clarithromycin 500mg PO 12 hourly
    OR

    Clindamycin 450mg PO 6 hourly for Quinsy

    Treat for 10 days in total

    Cystitis

    Obtain urine specimen first
    Male patients with UTI should be treated for 7 days
    Oral therapy for 3-5 days (for non-pregnant female patients)

    First line treatment for non-pregnant patient:
    Nitrofurantoin 100mg M/R capsules PO 12 hourly (only if GFR >45ml/min)
    Can use with caution to treat organisms resistant to other antibiotics if GFR 30-45ml/min. Increased risk of treatment failure and adverse effects. Treat on risk to benefit basis.

    OR if nitrofurantoin contraindicated:
    Pivmecillinam PO 400mg TDS (this is a penicillin)

    In non-severe penicillin allergy:

    CefaLEXin PO 500mg TDS

    Note: trimethoprim and amoxicillin are NOT recommended as emipircal treatment due to high resistance rates in organisms causing UTI. These agents may still be used to treat a known organism with proven susceptibility.

    If pregnant woman: See also Trust Obstetrics and Gynaecology Antimicrobial Guidelines

    CefaLEXin 500mg PO 8 hourly (for 7 days)

    PYELONEPHRITIS / URINARY SEPSIS

    Specimens: Urine and blood cultures

    First line treatment
    Gentamicin IV

    Or if Gentamicin is contraindicated:

    CefUROXime 1.5g IV 8 hourly

    Adjust treatment when results of culture and sensitivity are available (check Microbiology results) if no positive cultures consider switch to oral cefaCLOR 500mg 8 hourly.

    Duration: 7 - 10 days

    UTI IN PATIENTS WITH URINARY CATHETER

    Most patients with catheters develop bacteriuria.
    Dipstick testing of catheter urine specimens is not predictive of infection and must not be done.
    Send urine for culture only if the patient has clinical features of urinary tract infection or if patient is being screened for MRSA.

    Antibiotics are ONLY required if the patient is pyrexial or systemically ill. Then give:

    First line treatment:
    Gentamicin IV

    OR if gentamicin is contraindicated

    CefUROXime 1.5g IV 8 hourly

    If history of MRSA ADD Teicoplanin IV to CefUROXime

    Duration: 5 to 7 days

    Bladder washouts with antiseptics e.g. chlorhexidine are rarely indicated. They rarely eradicate organisms, may introduce infection, select out multi-resistant organisms, can cause inflammation of the bladder wall and therefore increase the likelihood of systemic invasion and they may also cause damage to the catheter. Saline bladder washouts are available as an alternative.

    MRSA colonised patients


    Most urinary tract infections caused by MRSA are in patients who are catheterised. MRSA is usually sensitive to gentamicin.

    Cystitis: MRSA can be sensitive to nitrofurantoin and trimethoprim. Review previous positive Microbiology prior to commencing empirical therapy. Discuss with Microbiology if required.

    Pyelonephritis/septicaemia: Gentamicin IV

    CHICKENPOX (Varicella)

    Immunocompromised patient or if pneumonitis is present:

    Adult: Aciclovir IV 10mg/kg every 8 hours IV for 7-10 days
    Dose must be adjusted in renal impairment.

    Use Adjusted Body Weight (ABW) in obese patients to avoid excessive dosing. First work out Ideal Body Weight for height (IBW):

    • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
    • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

    Then use Ideal Body Weight (IBW) and Total Body Weight (TBW) to work out ABW:
    • ABW (kg) = IBW + 0.4(TBW – IBW)


    ImmunoCOMPETENT adult or adolescent (older than 14 years):
    Aciclovir PO 800mg 5 times daily for 7 days
    OR
    Valaciclovir PO 1g 8 hourly for 7 days (use if compliance may be a problem)
    NB. The oral form is only effective if started within 24 hours of rash onset.

    ImmunoCOMPETENT children aged 1 month to 14 years:
    Aciclovir is NOT indicated

    HERPES SIMPLEX

    Superficial Herpes simplex (e.g. cold sores)
    Superficial Herpetic lesions will respond to topical aciclovir 5% cream applied 5 times daily provided it is initiated early in the infection.

    Herpes simplex stomatitis
    If necessary, give aciclovir orally or intravenously depending on clinical condition.

    Genital Herpes
    Aciclovir PO 400 mg three times a day

    Do not delay treatment if clinically suspected. Must start within 5 days of the start of the episode or while new lesions are forming. Continue for 5 days, or longer if new lesions are still forming while on treatment.

    Herpes simplex encephalitis See Meningitis and CNS Infections section

    HIV

    Patient must be referred to an Infectious Diseases Physician or the Sexual Health Clinic.

    Prophylaxis for health care workers occupationally exposed to HIV
    Contact Occupational Health or Microbiology for advice

    INFLUENZA TREATMENT AND PREVENTION

    During periods when Influenza A and/or B is known to circulating in the community patients showing symptoms consistent with Influenza infection should have swabs taken and be isolated pending results. Discuss with Microbiology and Infection Prevention and Control for advice if needed.

    Specific guidance on influenza treatment and prophylaxis is updated each influenza season. Refer to the Public Health England website for the latest guidance

    SHINGLES (Herpes zoster)

    Non-immunocompromised patients:
    Start oral treatment within 72 hours of rash onset for the patient groups below. If not possible to initiate treatment within 72 hours, consider starting treatment up to one week after rash onset if severe shingles, continued vesicle formation, older age or patient has severe pain.

    • Patients aged 50 years and above
    • Adults aged less than 50 years with any of the following criteria:
  • Ophthalmic involvement (seek immediate Ophthalmology advice)
  • Ramsay Hunt syndrome
  • Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
  • Moderate or severe pain
  • Moderate or severe rash
  • Eczema herpeticum

  • Aciclovir PO 800mg 5 times daily for 7 days
    OR
    Valaciclovir PO 1g 8 hourly for 7 days (use if compliance may be a problem)

    *Immunocompromised patients:
    Treatment may be started at any time before full crusting of lesions in immunocompromised adults.

    Adult: Aciclovir IV 10mg/kg every 8 hours IV for 7-10 days
    Dose must be adjusted in renal impairment.

    Use Adjusted Body Weight (ABW) in obese patients to avoid excessive dosing.
    First work out Ideal Body Weight for height (IBW):
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • Then use Ideal Body Weight (IBW) and Total Body Weight (TBW) to work out ABW
  • ABW (kg) = IBW + 0.4(TBW – IBW)

  • *Oral treatment (adult doses as stated below) may be considered if the rash is localised (involving single dermatome only) and patient systemically well.

    Aciclovir PO 800mg 5 times daily until 48h after lesions start crusting
    OR
    Valaciclovir PO 1g 8 hourly for 7 days

    MENINGITIS CONTACTS: PROPHYLAXIS

    Prophylaxis (antibiotics and vaccination) is organised by the Consultant in Communicable Disease Control (CCDC) as soon as the case has been notified. All cases of meningitis must be notified by telephone to the appropriate CCDC by the treating clinician.

    See contact numbers section for Public Health England contact details.

    There is no indication to take nasopharyngeal swabs from contacts before or after prophylaxis.

    MENINGOCOCCAL MENINGITIS/SEPTICAEMIA

    Who requires prophylaxis?


    The patient with meningitis/septicaemia treated with cefoTAXime (which may not eradicate carriage) prior to discharge from hospital. Patients treated with cefTRIAXone do not require prophylaxis.

    Household contacts within 7 days before onset, including frequent visitors.

    Boyfriend/girlfriend (mouth kissing contacts).
  • Prophylaxis for health care workers is NOT recommended unless the patient is within 24 hours of starting antibiotics and staff have given mouth-to-mouth resuscitation or have splashed the patient’s nasopharyngeal secretions into their unprotected face e.g. during suction or intubation. N.B. face masks and eye protection should always be worn when there is a risk of splashing secretions into face and eyes.

  • School contacts of single cases do not require prophylaxis.

    Antibiotic prophylaxis


    First line agent recommended for all age groups and in pregnancy is ciprofloxacin (note: this is an unlicensed indication).
    Dosage:
  • Adults and children over 12 years: 500mg PO stat
  • Children aged 5–12 years: 250mg PO stat
  • Children aged 1 month to 5 years: 125 mg PO stat

  • If patient aged <1 month or ciprofloxacin contraindicated, rifampicin is the drug of choice:
    Dosage:
  • Adults/child >12 years: 600mg PO 12 hourly for 2 days
  • Child (1-12 years): 10mg/kg PO 12 hourly for 2 days
  • Infants under 1 year: 5mg/kg PO 12 hourly for 2 days

  • The following side-effects of rifampicin must be explained to the patient.
  • This antibiotic colours urine orange.
  • Patients on the oral contraceptive pill should be warned to use alternative contraceptive measures for 1 month.
  • Patients should avoid alcohol.
  • Rifampicin increases the rate of clearance of warfarin and therefore reduces its effect.
  • Soft contact lenses may be discoloured permanently (do not wear them while on rifampicin).

  • Meningococcal vaccine
    For advice on vaccination of index case and close contacts discuss with Public Health England.

    Although there is no information to suggest that meningococcal vaccine is unsafe during pregnancy, it should only be given when this is unavoidable.

    HAEMOPHILUS INFLUENZAE TYPE B (HiB) MENINGITIS

    Prophylaxis is intended for protection of children under 10 years and vulnerable household contacts where there has been close, prolonged contact in a household type setting within 7 days of the index case developing invasive HiB disease.

    Who requires prophylaxis?
  • Household contacts: If vulnerable person in household e.g. any child under 10 years of age or immunosuppressed or asplenic person of any age, give to all household members (irrespective of age).
  • All room contacts, both teachers and children, where 2 or more cases of HiB disease have occurred in a play group, nursery, day care, crèche or primary school within 120 days. •
  • Index case (younger than 10 years) of confirmed or probable invasive HiB disease prior to discharge from hospital, and in all ages if there is a vulnerable person in household, to avoid second episodes and further transmission.


  • Antibiotic prophylaxis
    Rifampicin is the drug of choice:
    Dosage:
    Adults and children >3 months: 20mg/kg (max 600mg) PO once daily for 4 days
    Children <3 months: 10 mg/kg PO once daily for 4 days

    HiB vaccine Unimmunised and partially immunised index cases as well as contacts under 10 years of age should complete their primary course of HiB immunisation. Fully vaccinated index cases younger than 10 years should also have HiB antibody levels measured around 4 weeks after infection.

    ARTHRITIS (SEPTIC)

    Specimens: Joint aspirate and blood cultures.
    Urethral, cervical, pharyngeal and/or rectal swabs if gonococcal infection is suspected. An urgent gram film on aspirate should be requested and results should guide therapy.
    Likely pathogens: Staphylococcus aureus is the most common isolate.
    Gram negative organisms are more common in the elderly, those with history of recurrent UTIs and/or recent intra-abdominal pathology.

    EMPIRICAL THERAPY (PENDING JOINT FLUID GRAM STAIN RESULT)

    NO risk factors for gram negative infection and NO history of MRSA:
    Flucloxacillin 2g IV 6 hourly


    Risk factors for gram negative infection (or non-severe penicillin allergy) and NO history of MRSA:

    CefUROXime 1.5g IV 8 hourly


    History of MRSA (or severe penicillin allergy) and NO risk factors for gram negative infection:
    Teicoplanin IV


    Risk factors for gram negative infection AND history of MRSA:

    CefUROXime 1.5g IV 8 hourly
    AND
    Teicoplanin IV


    If patient has severe penicillin allergy discuss with Microbiology

    INITIAL THERAPY IF JOINT ASPIRATE SHOWS ORGANISMS ON GRAM STAIN

    Staphylococci (Gram positive cocci):
    Not penicillin allergic and no history of MRSA:
  • Flucloxacillin 2g IV 6 hourly

  • Non-severe penicillin allergy and no history of MRSA

  • CefUROXime 1.5g IV 8 hourly

  • Severe penicillin allergy or history of MRSA
  • Teicoplanin IV

  • A second agent should be added when antibiotic susceptibility tests are available e.g. sodium fusidate 500mg PO 8 hourly. Discuss this with Microbiology if needed.


    Gonococci (Gram negative cocci):

  • CefTRIAXone 2g IV once daily followed by Ciprofloxacin 500mg PO 12 hourly if organism is sensitive
  • If severe penicillin allergy discuss with Microbiology



  • Haemophilus (Gram negative cocobacilli):

  • CefUROXime 1.5g IV 8 hourly
  • If severe penicillin allergy discuss with Microbiology



  • Coliform (Gram negative bacilli):

  • CefUROXime 1.5g IV 8 hourly
  • If severe penicillin allergy discuss with Microbiology



  • Please note: Review treatment for targeted therapy when culture and sensitivity results are available. If Gram stain and culture are negative please consider an Orthopaedic/Rheumatology review prior to discharge.
    Injection of antibiotics into the joint is not usually necessary, may cause chemical synovitis and should only be performed on the advice of a consultant.
    Erythromycin and clarithromycin do not cross into synovial fluid in adequate amounts and should not be used.

    DURATION OF TREATMENT

    These are broad guidelines only. More prolonged therapy will be required when treatment has been delayed for more than a week after the onset of symptoms or if the patient is immunocompromised or when signs of joint inflammation have been slow to abate. Intravenous treatment should be given for at least 7-14 days (or until inflammatory signs have substantially diminished). The total course of antibiotics (intravenous plus oral) is shown below.

    Staphylococci/Coliform: 6 weeks (minimum)
    Haemophilus/Streptococci: 2-3 weeks (minimum)
    Gonococcal arthritis-dermatitis syndrome: 2 days intravenous cefTRIAXone
    Followed by 5-7 days oral ciprofloxacin 750mg 12 hourly.
    Gonococcal septic arthritis: 3 weeks

    ATHLETE’S FOOT

    Keep feet cool and dry. Wear cotton socks and non-synthetic footwear.

    For mild, non-extensive disease:
    Topical clotrimazole 1% cream 2-3 times daily for 4 weeks.

    Adult with severe or extensive disease, or when topical treatment has failed:
    Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment.

    Terbinafine 250mg PO once daily for 2-6 weeks
    OR
    Griseofulvin 1g PO once daily for 4-8 weeks and continued for 2 weeks after all signs of infection have resolved
    OR
    Itraconazole 100 mg PO once daily for 30 days or 200 mg twice a day for 7 days.

    Child with severe or extensive disease, or when topical treatment has failed:
    Seek Dermatology and Microbiology advice.

    BODY AND GROIN

    Refer patient to dermatologist if diagnosis is in doubt.

    Adult:
    Localised infection - topical clotrimazole cream 1% 2-3 times daily for 4 weeks
    Widespread infection - Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment.

    Terbinafine 250mg PO once daily for 2-6 weeks
    OR
    Griseofulvin 1g PO once daily for 4-8 weeks and continued for 2 weeks after all signs of infection have resolved
    OR
    Itraconazole 100 mg PO once daily for 30 days or 200 mg twice a day for 7 days.

    Child:
    Localised infection – topical clotrimazole cream 1% 2-3 times daily for 4 weeks
    Widespread infection – seek Dermatology and Microbiology advice.

    FUNGAL NAIL INFECTION

    Terbinafine 250mg PO once daily for 6 weeks to 3 months for finger nails and 3 to 6 months for toe nails (not for children)
    OR
    Itraconazole 200 mg twice a day for 1 week, with one subsequent course repeated after 21 days for finger nail infection and two further pulsed courses for toe nail infection.

    Other nail infections
    Scopulariopsis brevicaulis:
    This is one of the 10 most common fungal contaminants. It is omnipresent and rarely pathogenic but can cause nail infections which usually respond to terbinafine or griseofulvin.

    Candida sp:
    Topical 1% clotrimazole cream 3 times daily
    Keep hands dry

    SCALP (TINEA CAPITIS)

    Refer patient to dermatologist if diagnosis is in doubt.
    In urban areas in UK, tinea capitis is largely caused by Trichophyton tonsurans which is sensitive to terbinafine. In Europe and rural parts of the UK, it is largely caused by Microsporum canis (a zoophilic fungus that normally affects household pets) which is sensitive to griseofulvin. NB. If kerion (secondary bacterial infection) is present, treat concurrently with flucloxacillin or clarithromycin for at least the first 2 weeks.

    Treatment in adults:
    Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment. To reduce the risk of cross transmission to others, also prescribe a topical antifungal treatment to be used at least twice weekly during first two weeks of treatment with the oral antifungal (e.g. selenium sulphide shampoo, ketoconazole shampoo or terbinafine cream).

    Patient living in urban area:
    Terbinafine (off-label use) 250mg PO once daily for 4 weeks

    Patient living in rural area:
    Griseofulvin 1g PO once daily for 4-8 weeks (8-12 weeks in refractory cases) and continued for 2 weeks after all signs of infection have resolved.

    Review empirical treatment with mycology culture results.

    Treatment in children:
    If oral antifungal treatment is being considered in children, seek Dermatology and Microbiology advice.

    CURB-65 SCORING

    "Pneumonia” is assumed to include radiological evidence of consolidation.

    Investigation and management should be guided by the CURB-65 severity score
    (1 point for each):
    C = confusion (mini-mental test score 8 or less)
    U = urea > 7mmol/L
    R = respiratory rate ≥ 30 per minute
    B = systolic BP < 90 or diastolic BP ≤ 60
    65: age ≥ 65 years
    Note: the CURB-65 score alone can be misleading in terms of severity assessment for patients younger than 65 years of age.

    LOW SEVERITY CAP

    Low severity (CURB-65 score = 0 – 1): probably suitable for treatment at home.
    First line:
    Amoxicillin 500mg-1g PO 8 hourly

    If penicillin allergic:
    Clarithromycin 500mg PO 12 hourly

    If history of MRSA:
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily (if admitted)

    Doxycycline PO 200mg on first day then 100mg daily (if not for admission)

    MODERATE SEVERITY CAP

    Moderate severity (CURB-65 score = 2): Consider admission to hospital.

    If oral therapy is indicated
    First line oral treatment:
    Amoxicillin 1g 8 hourly PO AND clarithromycin 500mg 12 hourly PO.

    If penicillin allergy or history of MRSA:
    Doxycycline PO 200mg 12 hourly for 2 doses then 200mg once daily

    If IV therapy is indicated see guidance on high severity community acquired pneumonia

    HIGH SEVERITY CAP

    High severity (CURB-65 score ≥3)
    Initial management must be with IV antibiotics in hospital.

    First line treatment:
    Co-amoxiclav IV 1.2g 8 hourly AND clarithromycin IV 500mg 12 hourly

    IV to oral switch guidance:
    Co-amoxiclav 625mg 8 hourly PO AND clarithromycin 500mg 12 hourly PO

    If penicillin allergic:

    Levofloxacin 500mg IV every 12 hours

    IV to oral switch guidance:

    Levofloxacin 500mg PO every 12 hours

    If history of MRSA:

    Teicoplanin IV AND Ciprofloxacin 400mg IV 12 hourly

    IV to oral switch guidance:

    Linezolid 600mg PO 12 hourly AND ciprofloxacin 500mg PO 12 hourly

    If there is any reason why a patient cannot have IV therapy and oral therapy options are chosen please document reason in the patient notes.

    Rationalisation of therapy and oral switch

    Rationalise initial treatment regime with results of sputum cultures (aim for narrow spectrum of activity). Route of administration should be reviewed every 24 hours and documented in medical notes.
    Switch to oral route when the patient has been afebrile for 24 hours, shows signs of clinical improvement and oral intake is satisfactory. Base the choice of oral antibiotic on culture results, if available, otherwise use the oral switch guidance provided in these guidelines.

    Treatment duration

    5-7 days but 2-3 weeks may be necessary for patients with staphylococcal/ Gram negative or legionella pneumonia.

    MICROBIOLOGICAL INVESTIGATIONS

    CURB-65 score ≤ 2:
    Blood cultures (not needed for CURB 0-1)
    Sputum
    Pleural fluid if present

    Selected patients only
    Legionella antigen testing (in urine) if specific risk factors identified
    Acute and convalescent serum if atypical pneumonia suspected (for mycoplasma and chlamydia serology). Serology for legionella is no longer routinely performed.
    Sputum for Mycoplasma PCR

    CURB-65 score ≥ 3:
    Blood cultures
    Sputum (indicate on request card if legionella or Mycoplasma is suspected)
    Pleural fluid if present
    Urine for legionella and pneumococcal antigen testing
    Acute / convalescent serum as above.
    For patients being admitted to ITU, also send viral nose / throat swabs (in viral transport medium, which can be obtained from the Microbiology Laboratory) for respiratory viral PCR

    ANTIBIOTIC THERAPY FOR RED FLAG SEPSIS OF UNCLEAR SOURCE - ADULTS

    Antibiotics must be administered within 1 hour of recognition

    For infection of known focus follow the organ specific treatment guidance in the antimicrobial guidelines

    For infection of uncertain focus, prescribe and give antibiotics as described below then review the diagnosis after the first dose

    Always check previous positive microbiology results prior to starting antibiotics including MRSA status

    The empirical regimes below cover most organisms however, if the patient has a history of multi-resistant organisms not covered by the antibiotics given below, please discuss with a Microbiologist



    Step 1: Check allergy status and if patient is pregnant then prescribe the first dose as follows:

    NO penicillin allergy and NOT pregnantNon-severe penicillin allergy OR patient IS pregnantEvidence of severe or life threatening penicillin allergy (seek Microbiology advice if pregnant)

    Co-amoxiclav 1.2g IV
    PLUS
    *Gentamicin IV

    Cefuroxime 1.5g IV
    PLUS
    *Gentamicin IV

    If intra-abdominal infection or aspiration suspected or if patient is pregnant:
    ADD Metronidazole 500mg IV
    Teicoplanin IV 12mg/kg (round to nearest 200mg, dose limit 1.2g)
    PLUS
    *Gentamicin IV

    If intra-abdominal infection or aspiration suspected:
    ADD Metronidazole 500mg IV
    *For gentamicin dosing, follow the gentamicin prescription chart (in the inpatient drug chart) unless it is contraindicated. For pregnant patients follow the local gentamicin in pregnancy guidelines.

    Seek Microbiology advice if gentamicin contraindicated, do not omit gentamicin from the above regimens



    Step 2: Administer the first dose as follows. Subsequent doses must be given as per guidance in the orange ward drug files:
    Co-amoxiclav 1.2g: Dissolve with 20ml water for injection and give by IV injection over 3-4 minutes

    **Gentamicin: Doses of 480mg or less can be administered by IV injection over 3-5 minutes

    Cefuroxime 1.5g: Dissolve with 15ml of water for injections and give by IV injection over 3-5 minutes

    **Gentamicin: Doses of 480mg or less can be administered by IV injection over 3-5 minutes

    Metronidazole 500mg: Give ready prepared solution by IV infusion over 20 minutes
    Teicoplanin: Reconstitute using solvent provided. Doses of 1.2g or less can be administered by IV injection over 3-5 minutes

    **Gentamicin: Doses of 480mg or less can be administered by IV injection over 3-5 minutes

    Metronidazole 500mg: Give ready prepared solution by IV infusion over 20 minutes
    ** Gentamicin may contain higher than expected levels of histamine. Monitor the patient for histamine related adverse drug reactions as advised in the class 4 MHRA medicines defect information



    Step 3: After the first dose is given the diagnosis should be reviewed and ongoing therapy should be selected in accordance with antimicrobial guidelines and working diagnosis

    ANTIBIOTIC THERAPY FOR SEPSIS OF LIKELY SOURCE - ADULTS

    Septic patients require administration of appropriate antibiotic treatment within one hour of recognition of sepsis.

    See specific treatment guidance based on the likely focus of the infection.

    Always consider the following when selecting Antibiotic treatment:
  • Blood cultures and other appropriate specimens should be taken first
  • Allergy status?
  • C. difficile risk?
  • Drug interactions?


  • SEPSIS IN SPECIAL PATIENT GROUPS

    Neutropenic / Immunocompromised patient: See relevant sections of this guideline
    Neonate: See Trust Neonatal Antimicrobial Guidelines
    Pregnancy and post-partum: See Trust Obstetrics and Gynaecology Antimicrobial Guidelines.
    Babies (other than neonates) and Children: See Trust Paediatrics Antimicrobial Guidelines.

    SEVERITY OF INFECTION

    Infection severity Clinical manifestations
       
    Uninfected No local or systemic signs of infection.
    Mild Presence of ≥ 2 of the following involving only the skin and the subcutaneous tissue (without involvement of deeper tissues and NO systemic signs as described under severe infection):
  • Local swelling or induration
  • Erythema (>0.5 cm to ≤2 cm around the ulcer).
  • Local tenderness or pain
  • Local warmth
  • Purulent discharge (thick, opaque to white or sanguineous secretion)
  • Moderate Local infection (as described above) with erythema > 2 cm
    OR
    involving structures deeper than skin and subcutaneous tissues (e.g. abscess, osteomyelitis, septic arthritis, fasciitis),
    AND
    no systemic inflammatory response signs (as described below under severe infection).
    Severe Local infection (as described above) with ≥ 2 of the following:
  • WCC < 4 or > 12x10⁹/L
  • Temperature < 36ºC or >38ºC
  • Heart rate > 90bpm
  • Respiratory rate > 20/min or PaCO2 < 4.3kPa
  • SPECIMENS

    Blood cultures
    Wound swabs (should be taken from as deep as possible to increase the chance of detecting the causative organisms). N.B. wound swabs are unsatisfactory specimens for the diagnosis of pathogens causing deep infection such as osteomyelitis: if possible send tissue samples including bone sample when appropriate.

    Pathogens
    Aerobic Gram positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram negative bacilli, and those with foot ischaemia or gangrene may have obligate anaerobic pathogens. Review previous positive microbiology before starting empirical treatment. Discuss with Microbiology if required.

    TREATMENT OF INFECTION

    Antibiotic therapy must be used in conjunction with appropriate wound care (e.g. wound cleansing, debridement of any necrotic tissue) with input from the relevant specialists including Diabetologist and Tissue Viability Nurse.

    Severity Standard regimen Penicillin allergy History of MRSA
           
    Mild Flucloxacillin PO 500mg-1g 6 hourly
    Clindamycin PO 300mg-450mg 6 hourly
    Doxycycline PO 200mg every 12 hours for 2 doses then 200mg once daily.
    Moderate
    Ciprofloxacin 500mg PO 12 hourly
    AND
    Clindamycin 600mg PO 8 hourly
    Doxycycline PO 200mg every 12 hours for 2 doses then 200mg once daily
    AND
    Metronidazole 400mg PO 8 hourly
    AND
    Rifampicin 450mg PO 12 hourly
    Severe Piperacillin-tazobactam 4.5g IV 8 hourly

    For IV to oral switch discuss with Microbiology
    Teicoplanin IV
    AND

    Ciprofloxacin 400mg IV 12 hourly
    AND
    Metronidazole 400mg PO 8 hourly

    For IV to oral switch discuss with Microbiology


    Rationalise antibiotics with the results of culture and the clinical response to the empirical regimen.
    Intravenous antibiotic therapy should be switched to oral therapy as soon as clinically possible.

    Duration of Antibiotic therapy
    Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until the wound has healed. Suggested course lengths:

    Mild infections: 1 to 2 weeks
    Moderate/severe infections: 2 to 4 weeks
    Osteomyelitis: at least 6 weeks is generally required.
    Preseptal cellulitisOrbital Cellulitis
  • No chemosis
  • No proptosis
  • No ophthalmoplegia
  • No visual loss
  • Painful eye movements
      +/- chemosis
      +/- proptosis
      +/- restricted eye movements
      +/- visual loss
    Mild severity:

    Co-amoxiclav 625mg PO 8 hourly

    If mild severity and penicillin allergic, please discuss with Microbiology

    Moderate to severe infection (or if no response to Co-amoxiclav in 24 hours):

    First line treatment:

    CefTRIAXone 2g IV 12 hourly for 24 hours then reduce to 2g once daily

    If severe penicillin allergy:

    Ciprofloxacin 750mg PO 12 hourly
    AND
    Clindamycin 600mg PO 8 hourly

    If history of MRSA: Consult with microbiology.

    Refer to Ophthalmology and ENT if no response within 24 hours.
    Refer to Ophthalmology and ENT

    First line treatment:

    IV CefTRIAXone 2g 12 hourly for 24 hours then reduce to 2g once daily
    ADD in IV Metronidazole 500mg 8 hourly if no improvement in 12-18 hours.

    If severe penicillin allergy:

    IV Ciprofloxacin 400mg 12 hourly
    AND
    IV Clindamycin 600mg 6 hourly

    IV antibiotics for 24-48 hours, followed by oral antibiotics for 7-14 days if satisfactory response.

    IV to oral switch treatment:

    Co-amoxiclav 625mg PO 8 hourly

    If penicillin allergy:

    Ciprofloxacin 750mg PO 12 hourly
    AND
    Clindamycin 600mg PO 8 hourly

    If history of MRSA consult with microbiology.

    ACUTE OTITIS MEDIA

    Specimen: ear swab
    Pain relief e.g. paracetamol
    Wait up to 72 hours (80% resolve spontaneously without antibiotics).
    Treatment may be started earlier than 72 hours if immunocompromised or if patient deteriorating:

    Amoxicillin 500mg-1g PO 8 hourly
    OR
    Clarithromycin 500mg PO 12 hourly

    Duration: 5 days

    OTITIS EXTERNA

    Furunculosis
    Specimen: ear swab
    Pain relief e.g. paracetamol and local heat
    If severe: flucloxacillin 500mg-1g PO 6 hourly or clarithromycin 500mg PO 12 hourly

    Diffuse otitis externa
    Specimen: ear swab
    Keep ears dry. Do not pick.
    Pain relief if required.

    First line: Avoid antibiotics wherever possible and use 2% acetic acid (e.g. EarCalm spray)
    Second line: Topical gentamicin 0.3% (contraindicated in perforated tympanic membrane).
    OR
    Topical ciprofloxacin 0.3% (unlicensed)

    Malignant otitis externa
    Specimens: ensure specimens for culture including tissue/pus are sent before starting antibiotic therapy.

    Discuss treatment options with a Microbiologist.

    VACCINES

    Patients who suffer with asplenia or hyposplenia (including homozygous sickle cell disease and coeliac syndrome) are at increased risk of overwhelming bacterial infection. Infection is most commonly pneumococcal but other organisms such as Haemophilus influenzae type b and meningococci may be involved. This risk is greatest in the first two years following splenectomy and is greater amongst children but persists into adult life.



    Vaccination schedule: Adults and Adolescents aged over 11 years

    VACCINE DOSING SCHEDULE BOOSTER
    Initial vaccinations – give all on day one of immunisation
    Pneumococcal polysaccharide vaccine (PPV: 23 valent)
    (Pneumovax II®)
    NOTE - Severely immunocompromised adults and children over 5 years (e.g. bone marrow transplant patients) should instead be offered a single dose of PCV13 vaccine followed by PPV23 at least two months later (irrespective of routine childhood vaccinations).
    One dose Booster every 5 years

    Immunity may decline rapidly in certain patient groups. Monitoring of antibody levels may be useful
    Menitorix® Combined Vaccine
    Containing:
    Haemophilus influenzae type b (Hib)
    AND
    Meningococcal group C conjugate vaccine
    One dose of Hib/MenC (Menitorix®) Booster not currently required
    Meningococcal group B vaccine (Bexsero®) One dose (first of two) Second dose required after one month
    Further vaccinations – to be given after the initial vaccinations as described below
    Meningococcus ACWY conjugate vaccine (Menveo® or Nimenrix®)
    NOTE – this vaccine is not required in severely immunocompromised adults and children aged over 5 years who required the PCV13 vaccine as above.
    One dose to be given one month following the Hib/MenC vaccine Further booster not currently required
    Meningococcal group B vaccine (Bexsero®) One dose (second of two) to be given one month following the first dose Further booster not currently required
    Influenza vaccine 1 dose annually from September to November via patient’s GP

    Refer to Department of Health Immunisation Against Infectious Disease: The Green Book for latest updates on vaccine schedules

    Vaccines given at the same time should be given at a separate site, preferably a separate limb. If given in the same limb they should be given at least 2.5cm apart.

    Splenectomy Vaccination Schedule for children
    Please note there is a different vaccination schedule available for children, which is dependent on age and previous exposure to vaccines Please see PHE Immunisation against infectious diseases guidance (The Green Book) which is available at www.doh.gov.uk.

    Immunisation for travellers
    Individuals travelling to countries of risk (see BNF) should be immunised with a meningococcal vaccine covering serotypes A, C, W135 and Y (ACWY Vax). Proof of vaccination with the quadrivalent (A, C, W135, and Y) meningococcal vaccine is required for those travelling to Saudi Arabia as pilgrims for Hajj or Umrah. Travellers should be immunised even if they have already received meningococcal group C conjugate vaccine. This vaccine should not be given to infants of less than two months. (See www.nathnac.org for up to date information on countries affected by outbreaks).

    ANTIBIOTICS

    Lifelong antibiotic prophylaxis should be offered to all patients considered to be at continued high risk of pneumococcal infection.
    Antibiotic prophylaxis should be continued for the first two years post splenectomy and in all children, at least until the age of 16 years. Penicillin V is preferred unless cover is also needed against Haemophilus influenzae for a child (in which case give amoxicillin) or unless the patient is allergic to penicillin (give erythromycin). Post splenectomy patients must start prophylactic antibiotics immediately.

    Factors associated with high risk of invasive pneumococcal disease in hyposplenism include: aged less than 16 years or greater than 50 years, inadequate serological response to pneumococcal vaccination, a history of previous invasive pneumococcal disease, and splenectomy for underlying haematological malignancy particularly in the context of on-going immunosuppression. Lifelong compliance with prophylactic antibiotics is problematic. If the patient does not continue to be at high risk as per the criteria above, the patient must have antibiotic prophylaxis until at least 2 years after splenectomy. Patients should be advised to have an emergency supply of amoxicillin or erythromycin to take in the event of fever plus be advised to seek medical attention urgently.

    Antibiotic Age Dose
         
    PENICILLIN V Children under 5 years
    Children 5-12 years
    > 12 years and adults
    125mg bd
    250mg bd
    500mg bd
    AMOXICILLIN Child under 5 years
    Child > 5 years and adults
    125mg bd
    250mg bd
    ERYTHROMYCIN Child under 2 years
    Child 2-8 years
    Child > 8 years and adults
    125mg od
    250mg od
    500mg od

    OTHER MEASURES

    Other measures to reduce risk include:
  • Patients should be asked to consult if they have a febrile illness and may be given a stock of antibiotics to start treatment by themselves. All asplenic patients should carry a card and/or Medic-Alert bracelet or necklace. A splenectomy patient information leaflet and warning card should be given to any new patients (available from Pharmacy).
  • When travelling abroad patients should obtain advice from the designated travel advice centre (e.g. Liverpool School of Tropical Medicine) to ensure precautions are adequate and up to date.
  • Patients should avoid malaria (which is more severe in asplenic patients) by avoiding malaria areas or, if going to such areas, adhere scrupulously to antimalarial prophylaxis and anti-mosquito precautions.
  • Avoid tick bites as there is a risk of babesiosis and Lyme disease
  • Provide patient with NHS splenectomy leaflet, available from Pharmacy


  • N.B. Caution with management of animal bites in this vulnerable population. Seek advice as necessary.

    SPECIMEN TAKING

    Specimens Blood cultures (minimum of two sets)
    Bone/pus/aspirate if available
    An urgent gram film on aspirate should be requested and results should guide therapy

    ACUTE OSTEOMYELITIS

    Staphylococcus aureus is the most common isolate. Gram negative organisms are more common in the elderly, those with history of recurrent UTIs and/or recent intra-abdominal pathology.

    NO risk factors for gram negative infection and NO history of MRSA:
    Flucloxacillin 2g IV 6 hourly


    Risk factors for gram negative infection (or non-severe penicillin allergy) and NO history of MRSA:

    CefUROXime 1.5g IV 8 hourly


    History of MRSA (or severe penicillin allergy) and NO risk factors for gram negative infection:
    Teicoplanin IV


    Risk factors for gram negative infection AND history of MRSA:

    CefUROXime 1.5g IV 8 hourly
    AND
    Teicoplanin IV


    If patient has severe penicillin allergy discuss with Microbiology

    Therapy may need to be changed when results of culture and sensitivity are available including adding a second agent (e.g. rifampicin or sodium fusidate dependent on organism isolated and sensitivities).

    CHRONIC OSTEOMYELITIS

    It is critical to have good specimens for culture ideally before starting antibiotics i.e. at least two sets of blood cultures, deep pus/tissue specimens from affected site.

    Await culture and sensitivity results before starting therapy if possible, but do not delay antibiotic treatment if there are signs of systemic sepsis. Parenteral antibiotics should be given for at least 3 weeks otherwise the relapse rate is 20%. Prolonged courses (e.g. several weeks or months) of oral antibiotics may then be required depending on pathogen isolated and clinical progress.

    SPECIMENS

    Likely pathogens
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Anaerobes
  • Enterobacteriaceae
  • Streptococci
  • Mycoplasma

  • Specimens Cervical swab for gonococcal culture (plain transport medium).
    Urethral/vaginal swabs in Aptima transport medium for chlamydia and Neisseria gonorrhoeae PCR. NB: In women, PCR for chlamydia and Neisseria gonorrhoeae on first void urine is less sensitive compared with genital swabs. Culdocentesis fluid if available.
    Blood cultures if systemic illness.
    Consider testing for HIV and syphilis if risk factors are present.

    Discuss with Integrated Sexual Health Service (01695 656550) and Obstetrics and Gynaecology.

    TREATMENT

    Mild/moderate disease or outpatient treatment


    CefTRIAXone 500mg stat intramuscularly
    AND
    Doxycycline 100mg PO 12 hourly for 14 days. If pregnant or breastfeeding DO NOT use doxycycline – see below instead
    AND
    Metronidazole 400mg PO 12 hourly for 14 days.

    If pregnant patient or breastfeeding use erythromycin PO 500mg 6 hourly for 14 days in place of doxycycline in the above regimen.

    If severely penicillin allergic contact Microbiology for advice


    Severe disease or inpatient treatment


    CefTRIAXone 2 g IV once daily to be continued until 24 hours after clinical improvement
    AND
    Metronidazole IV 500 mg 8 hourly for a total of 14 days.
    AND
    Doxycycline PO 100 mg 12 hourly for a total of 14 days.
    If pregnant or breastfeeding DO NOT use doxycycline – see below instead

    Change to PO metronidazole 400mg 12 hourly 24 hours after clinical improvement.
    If patient unable to tolerate oral treatment, use clarithromycin 500mg IV 12 hourly in place of PO doxycycline.

    If patient pregnant or breastfeeding, substitute erythromycin PO 500mg 6 hourly for doxycycline in the above regime.

    If severe penicillin allergy:

    Clindamycin 900mg IV 8 hourly
    AND
    Gentamicin IV

    Followed by: Doxycycline 100mg PO 12 hourly AND Metronidazole 400mg PO 12 hourly (avoid doxycycline and seek advice in pregnancy).

    Total duration of treatment: 14 days

    TERMINATION OF PREGNANCY

    Termination of Pregnancy (TOP) Endocervical swab & urine sample for Chlamydia prior to TOP
    Surgical TOP Chlamydia trachomatis Doxycycline 200mg PO single dose 2 hours before the procedure
    OR
    Azithromycin 500mg PO single dose 2 hours before the procedure
    Patients with positive Chlamydia swabs MUST be referred to the Sefton Sexual Health Service on 01704 513303

    OTHER OBSTETRICS PROCEDURES

    Clinical diagnosis Treatment advice Comments
         
    Pre-term Pre-labour Rupture of Membranes Erythromycin 250mg PO 6 hourly for 10 days or until delivery (whichever is sooner) Take HVS before prescribing antibiotics.

    Refer to Southport and Ormskirk NHS Trust Obstetrics and Gynaecology Guidelines No.26 Pre-labour Rupture of Membranes for further guidance.
    Maternal carriage of Group B Streptococcus Benzylpenicillin 3g IV initially then 1.5g IV every 4 hours until delivery

    Non-severe Penicillin Allergy:
    CefUROXime IV 1.5g every 8 hours until delivery

    Severe Penicillin Allergy:
    Vancomycin IV 1g every 12 hours until delivery (contact Pharmacy for advice in patients with renal impairment)
    If a woman is found to be a GBS carrier, antibiotics should be given at the onset of labour or when membranes have ruptured and continued until delivery.

    Pre-dose vancomycin level should be taken immediately before the 3rd dose, then the dose should be given. Target level is 10-15mg/L.
    Caesarean Section Cefuroxime 1.5g IV
    AND
    Metronidazole 500mg IV at induction
    ADD Teicoplanin IV 800mg if MRSA colonised


    Severe Penicillin Allergy
    Clindamycin IV 600mg
    AND
    Gentamicin IV 120mg prior to incision
     
    Evacuation of retained products of conception Cefuroxime 1.5g IV
    AND
    Metronidazole 500mg IV at induction

    Severe Penicillin Allergy
    Contact Medical Microbiologist
     
    Prophylaxis for Infective Endocarditis No longer routinely recommended (See BNF). In specific cases discuss with a Consultant Medical Microbiologist or Consultant Cardiologist.

    GOOD PRACTICE IN ANTIBIOTIC PRESCRIBING


    Identifying the likely source of infection
    Patients with signs of sepsis should have blood cultures taken and any other appropriate samples such as sputum and urine preferably prior to initiating empirical antibiotic therapy. Previous culture reports should be used to guide empirical therapy. Appropriate samples include recent sputum samples for suspected respiratory tract infections, recent catheter specimens of urine (CSU) for suspected urinary sepsis and intra-operative samples if infection suspected during procedure.

    Selecting Antimicrobial Agents
    The Obstetrics and Gynaecology Antimicrobial Guidelines should be followed when selecting antimicrobial therapy. For situations not dealt with by these or whenever the prescriber is uncertain, advice should be sought from a senior member of the clinical team who can discuss with a Consultant Medical Microbiologist, as necessary. Whenever possible, samples for Microbiological culture should be taken prior to commencing antimicrobial therapy.

    Always consider whether an antibiotic is needed:
    • Is the infection bacterial or could it be viral?
    • Is it post-operative pyrexia associated with tissue damage and repair?
    • Is the patient stable enough to wait for culture results before starting therapy?
    • Bacteria isolated from a specimen may represent colonisation or overgrowth NOT infection. Colonisation rarely requires antibiotic therapy.

    Check for factors which will affect drug choice e.g.

    • For patients who are pregnant (or likely to be pregnant) or breastfeeding see section on Prescribing Antibiotics in Pregnancy and Lactation.
    • Is the patient allergic to any antibiotic? Do not use penicillin or cephalosporins (up to 6.5% cross-over allergy - BNF) in severe cases of penicillin allergy i.e. anaphylaxis or angio-oedema. (See individual sections for suitable alternatives). Cephalosporins can be used after risk assessment in cases of non-severe penicillin allergy i.e. rash. Always document the risk assessment in the patient’s notes
    • Does the patient have impaired renal function (beware of possible reduced renal function in presence of normal creatinine) or liver function.
    • Interactions with other medications.

    Check the appropriate dose is prescribed, if uncertain check in the British National Formulary (BNF) or contact Pharmacy or Microbiology. The need for antibiotic therapy should be reviewed on a daily basis.

    For most infections 5-7 days is sufficient. All intravenous (IV) antibiotics should be given for no more than 48 hours without review and consideration of oral alternatives. Switch to oral (PO) antibiotics should be based upon clinical indicators such as fever defervescence for at least 24 hours, reducing CRP and marked clinical improvement. Switch to an appropriate alternative agent should also be made based upon new microbial or other information.

    By following the guidelines it is intended that a more rational approach will not only prevent unnecessary treatment but also reduce the development of resistant organisms.

    In 2018 the ARK-Hospital project will be launched in this Trust. ARK is a system designed to improve antibiotic ‘review and revise’ click here for more information.

    Prescribing in Pregnancy – General Principles
    Drugs taken at any time during pregnancy or around the time of conception can have harmful effects on the foetus. It is therefore important to bear this in mind when prescribing for a woman who may become pregnant, as well as for those known or suspected to be pregnant at the time of consultation.

    No drug is safe beyond all doubt and prescribing should only take place if the benefit outweighs any potential risks.
    When considering treatment with antibacterial agents during pregnancy, the following factors should be considered:

    • the severity of the maternal infection
    • the effects of any fever present on the pregnancy
    • the effects of failing to treat the mother
    • the potential fetotoxicity of the drugs to be used

    Where possible, the results of culture and sensitivity tests should be available before making a treatment choice.


    Prescribing in Lactation – General Principles
    Prescribing should only take place if the benefit outweighs any potential risks to EITHER the mother or infant. Avoid the use of drugs known to cause serious toxicity in adults or children. Drugs licensed for use in infants do not generally pose a hazard. Neonates (and particularly premature infants) are at greater risk from exposure to drugs via breast milk, because of immature excretory functions and the consequent risk of drug accumulation – is the infant full-term, normal birth weight and healthy?
    Choose a regimen and route of administration that presents the minimum amount of drug to the infant. It is best to avoid long-acting preparations, especially those of drugs likely to cause serious side effects, as it is difficult to time feeds to avoid significant amounts of drug in breast milk. Multiple drug regimens may pose an increased risk especially when adverse effects are additive. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Avoid new drugs if a therapeutically equivalent alternative that has been more widely used is available.

    The purpose of this information is to act as a GUIDE only. Further detailed advice for individual patients is available by ringing the Medicines Information Pharmacist on extension 5157.

    PREGNANCY AND LACTATION PRESCRIBING

    <
    Antibiotic Pregnancy Breastfeeding
    Cephalosporins

    Cefalexin
    Cefuroxime
    May be administered.

    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-CEPHALOSPORINS-IN-PREGNANCY/
    May be administered.

    Although unlikely, monitor infant for gastro-intestinal disturbances and oral candida – especially if given IV, high doses or prolonged use.
    https://www.sps.nhs.uk/articles/safety-in-lactation-cephalosporins-carbapenems-and-other-beta-lactams/
    Clindamycin Use with caution.

    Clindamycin crosses the placenta. Limited experience and safety data in pregnancy.
    Use with caution.

    Monitor infant for gastro-intestinal disturbances and oral candida infection, especially for prolonged periods or in high doses, although these effects are unlikely to occur.
    https://www.sps.nhs.uk/articles/safety-in-lactation-clindamycin/
    Clotrimazole (Topical) May be administered.

    If using the pessary rather than topical cream then use of the applicator should be avoided.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-CLOTRIMAZOLE-IN-PREGNANCY/
    May be administered.

    Minimise contact of infant with the treated areas. Remove all products from the breast before feeding.
    https://www.sps.nhs.uk/articles/safety-in-lactation-antifungal-skin-preparations/
    Fluconazole Avoid in pregnancy.

    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-FLUCONAZOLE-IN-PREGNANCY/
    May be administered.

    Significant amounts in breast milk. Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/medicines/fluconazole/
    Gentamicin Use with caution.

    Ototoxicity has been reported following in utero exposure to other aminoglycosides. Gentamicin is the preferred aminoglycoside during pregnancy as there is more documented experience of its use than for other aminoglycosides.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-AMINOGLYCOSIDE-ANTIBIOTICS-IN-PREGNANCY/
    Use with caution.

    Negligible amounts of aminoglycosides are found in breast milk. Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/medicines/gentamicin/
    Macrolides

    Erythromycin
    Clarithromycin
    Erythromycin is the preferred choice during pregnancy because there is more documented experience of its use than for other macrolides. Clarithromycin should be avoided where possible due to potential increased risk of spontaneous abortion. http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-MACROLIDES-IN-PREGNANCY/ Use with caution.

    Evidence suggests risk of hypertrophic stenosis in infants, especially if infant exposed in first 2 weeks after birth. This risk may be higher with erythromycin. Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/articles/safety-in-lactation-macrolides/
    Metronidazole Use with caution.

    Avoid high dose regimens.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-METRONIDAZOLE-IN-PREGNANCY/
    Use with caution.

    Oral route is preferred as this produces slightly lower levels in milk. Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/articles/safety-in-lactation-metronidazole-and-tinidazole/
    Nitrofurantoin Use with caution.

    Avoid in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency.
    Avoid in 3rd trimester and during labour and delivery because of the theoretical possibility of haemolytic anaemia in the foetus or neonate.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-NITROFURANTOIN-IN-PREGNANCY/
    Use with caution.

    Evidence in breastfeeding is for short-term use only. Although unlikely, monitor infant for gastro-intestinal disturbances and oral candida infections – especially in high doses.
    https://www.sps.nhs.uk/medicines/nitrofurantoin/
    Penicillins
    Amoxicillin
    Benzylpenicillin
    Flucloxacillin
    May be administered.

    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-PENICILLINS-IN-PREGNANCY/
    May be administered.

    Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/medicines/amoxicillin/
    Quinolones
    Ciprofloxacin
    Not recommended.

    Theoretical risk of arthropathy. Use in pregnancy is not generally recommended, except for the treatment of serious or life-threatening conditions unresponsive to other antibiotic therapies considered suitable for use in pregnancy.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-QUINOLONES-IN-PREGNANCY/
    Use with caution.

    Avoid in infants with known G6PD deficiency due to the risk of haemolysis. Generally accepted but concerns about adverse effects on infants developing joints, although this has only been reported in infants taking quinolones directly. Calcium in breastmilk may prevent or reduce infant absorption of quinolones. Although unlikely, monitor infant for gastro-intestinal disturbances and oral candida infections – especially in high doses.
    https://www.sps.nhs.uk/medicines/ciprofloxacin/
    Tetracyclines

    Doxycycline
    Avoid in pregnancy.

    Use of tetracycline antibiotics in pregnancy is associated with discolouration of teeth and there are limited data to support transient effects on foetal bone growth.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-TETRACYCLINE-IN-PREGNANCY/
    Use only if no alternative.

    If other antibiotics are not appropriate, tetracycline is the drug of choice from this class. Short term use (less than 3 weeks) is acceptable, but long term use (e.g. in acne) is not advisable. Concerns regarding bone deposition and possible staining of infants’ dental enamel have not been confirmed and are unlikely during short term.
    https://www.sps.nhs.uk/medicines/doxycycline/
    Trimethoprim Use with caution.

    Theoretical concerns that use during pregnancy may increase risk of neural tube defects. Folate supplementation with high dose (5mg) folic acid is recommended in all women treated with trimethoprim during the first trimester.
    http://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-TRIMETHOPRIM-IN-PREGNANCY/
    Use with caution.

    Generally, sulphonamides and trimethoprim are acceptable to use while breastfeeding full term and healthy infants. Although unlikely, monitor infant for gastro-intestinal disturbances and oral candida infections – especially in high doses.
    https://www.sps.nhs.uk/medicines/trimethoprim/
    Vancomycin Use with caution.

    Only use for life threatening conditions.
    Blood levels should be monitored carefully to minimise the risk of foetal toxicity.
    May be administered.

    Although unlikely, monitor infant for gastro-intestinal disturbances – especially if used for prolonged periods or high doses.
    https://www.sps.nhs.uk/medicines/vancomycin/


    If you require assistance in making a patient-specific risk assessment, please telephone UK Teratology Information Service (UKTIS) on 0344 892 0909 to discuss the case with a teratology specialist

    Further information for prescribing in pregnancy and breastfeeding include:

    Medicines Information - Southport and Ormskirk Hospitals NHS Trust 01704 705157

    Toxbase - http://www.medicinesinpregnancy.org

    SEPSIS

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Intrapartum Sepsis Various including anaerobes CefUROXime IV 1.5g 8 hourly
    AND
    Metronidazole IV 500mg 8 hourly

    Consider Gentamicin IV in addition to above based on risk/benefit assessment.

    Severe penicillin allergy
    Contact Medical Microbiology
    If patient does not improve on initial therapy OR if patient is known to be colonised with multi-resistant organisms (e.g. ESBLs) additional broad spectrum antibiotic cover should be discussed with the Consultant Medical Microbiologist as necessary.
    Post-partum sepsis Various including anaerobes CefUROXime IV 1.5g 8 hourly
    AND
    Metronidazole IV 500mg 8 hourly
    AND
    Gentamicin IV

    Severe Penicillin allergy:
    Clindamycin IV 600mg 6 hourly
    AND
    Gentamicin IV
    Discuss with Medical Microbiology if condition does not improve on initial treatment.

    Caution if mother is breast-feeding
    If Toxic Shock is suspected see toxic shock section of these guidelines and discuss with Microbiology urgently

    SKIN AND SOFT TISSUE INFECTION

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Superficial Infections Staph. aureus
    Haemolytic streptococci
    Flucloxacillin PO 500mg 6 hourly for 5 days

    Penicillin Allergy
    Erythromycin PO 500mg 6 hourly for 5 days
    Take a swab if pus is present. A reddened wound does not always require antibiotics. Only use if infection is suspected or microbiologically confirmed.

    NB. Erythromycin is the macrolide of choice in pregnancy and breastfeeding.
    Post Natal Wound Infection Staph. aureus
    Streptococci
    Anaerobes
    Coliforms
    Flucloxacillin IV 2g 6 hourly
    AND
    Gentamicin IV
    AND
    Metronidazole IV 500mg 8 hourly

    Penicillin Allergy
    CefUROXime IV 1.5g 8 hourly
    AND
    Metronidazole IV 500mg 8 hourly

    In severe penicillin allergy
    Clindamycin IV 600mg 6 hourly
    AND
    Gentamicin IV once daily
    Use microbiology results to guide ongoing therapy.

    N.B. This guidance is for POST NATAL, NOT PRE-NATAL wound infections.
    For Severe Post Natal Wound infection or if MRSA is suspected please discuss with a Consultant Medical Microbiologist.
    Mastitis in pregnancy and breastfeeding Staph. aureus
    Flucloxacillin PO 500mg every 6 hours

    Penicillin Allergy
    Erythromycin PO 500mg every 6 hours
    The mother should continue to breastfeed if possible. Counsel that these antibiotics are in breast milk in small amounts. Infants not normally affected but may have loose stools and become more irritable. Urgent clinical review is indicated if unresponsive to oral therapy within 48 hours.
    Duration: 10-14 days
    Post-Natal Breast Abscess Staph. aureus Non-severe infection
    Flucloxacillin PO 500mg every 6 hours

    Penicillin Allergy
    Clindamycin PO 450mg 8 hourly

    Severe infection (inpatient)
    Flucloxacillin IV 2g 6 hourly
    AND
    Metronidazole IV 500mg 8 hourly

    Penicillin Allergy
    Discuss with Microbiology
    Duration of treatment:
    10-14 days according to clinical response.

    Drainage of abscess is advised.

    N.B. This guidance is for POST NATAL Breast Abscess. If patient still pregnant or is breastfeeding suggest discuss antibiotic options with Consultant Medical Microbiologist.

    URINARY TRACT INFECTION

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Cystitis in pregnancy Coliforms CefaLEXin PO 500mg 8 hourly
    OR
    Nitrofurantoin PO 100mg M/R 12 hourly if GFR > 45ml/min Only use this in the 1st and 2nd trimester. AVOID in the 3rd trimester.

    Duration of therapy 7 days
    Subsequently target therapy against organisms isolated from MSU

    N.B. Urine specimens should be sent regardless of urine dipstick test results
    Pyelonephritis in pregnancy Coliforms CefUROXime IV 1.5g 8 hourly

    In severe penicillin allergy
    Contact Medical Microbiology
    Refer to Urologists.
    Always take blood cultures and a urine specimen.
    Total duration of treatment, including appropriate IVOST is 10-14 days.
    Switch to oral antibiotics after symptoms and signs have resolved for 48 hours.
    Culture results will guide oral therapy.
    Asymptomatic bacteriuria in pregnancy Coliforms Treat according to sensitivity result

    CefaLEXin PO 500mg TDS
    OR
    Nitrofurantoin PO 100mg M/R 12 hourly if GFR > 45ml/min Only use this in the 1st and 2nd trimester. AVOID in the 3rd trimester.

    OR
    If a urine culture result shows organism sensitive to amoxicillin (check for penicillin allergy):
    Amoxicillin PO 500mg TDS
    If a pregnant patient has a positive urine culture, collect a repeat urine sample and treat if positive.
    Duration: 7 days

    VAGINAL DISCHARGE

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Vaginal Candidiasis in pregnancy Candida sp. Use Clotrimazole PV 500mg pessary once only and Clotrimazole 1% cream BD-TDS for 7 days

    DO NOT USE Fluconazole if there is any suspicion of pregnancy.
    Seek specialist advice if recurrent or refractory to treatment.
    Trichomoniasis in pregnancy Trichomonas vaginalis Discuss treatment options with a Consultant Medical Microbiologist or Consultant in GUM Refer to Genito Urinary Medicine
    The patient’s partner should be treated simultaneously.
    Bacterial vaginosis in pregnancy Gardnerella vaginalis
    Mobiluncus
    Bacteroides
    and Mycoplasma.
    Clindamycin 2% Cream PV 5g at night for 7 nights (Preferred treatment in first trimester).
    OR
    Metronidazole PO 400mg BD for 7 days
    Discuss refractory or recurrent cases with a Consultant Medical Microbiologist

    Do not use high single doses of Metronidazole in pregnancy.
    Infections with Chlamydia, N. gonorrhoeae, genital herpes or TV should always be referred to the Sefton Sexual Health Service on 01704 513303

    VIRAL INFECTIONS IN PREGNANCY

    Viral infections in pregnancy
       
    Herpes Simplex Virus (HSV) Infection Herpes Simplex Virus (HSV) Infection, Obstetrics & Gynaecology Guideline No. 16, Southport & Ormskirk Hospitals NHS Trust, 2012.
    Chickenpox / Varicella-Zoster Virus Infection in Pregnancy Management of Chickenpox / Varicella-Zoster Virus Infection in Pregnancy, Obstetrics & Gynaecology Guideline No. 11, Southport & Ormskirk Hospitals NHS Trust, 2014
    HIV British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review)

    PELVIC INFLAMMATORY DISEASE

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Mild or Moderately Severe or Outpatient Chlamydia trachomatis
    Ureaplasma
    urealyticum
    Neisseria gonorrhoeae
    Gram negative bacilli
    Chlamydia trachomatis
    Anaerobes
    CefTRIAXone IM 500mg once only
    THEN
    Doxycycline PO 100mg 12 hourly
    (Do NOT give doxycycline in pregnancy or breastfeeding)
    AND
    Metronidazole PO 400mg 12 hourly

    Treat for 14 days

    If patient is pregnant or breastfeeding
    Substitute PO Erythromycin 500mg QDS for Doxycycline in above regimen.
    In severe penicillin allergy
    Contact Medical Microbiology
    Symptoms include purulent vaginal discharge, pyrexia >38°C, nausea or vomiting.

    Often due to Sexually Transmissible Infection. Do NOT treat until swabs are taken. Full infection screen should be carried out of urethra, endocervical and high vaginal swabs for routine culture and Chlamydia and gonorrhoea testing.
    Severe infections: In addition to a full infection screen, take blood cultures and consider laparoscopy.
    Discuss with Consultant in Genitourinary Medicine (01704-513303 or ext 4492).
    Severe CefTRIAXone IV 2g daily
    AND
    Doxycycline PO 100mg 12 hourly (Do NOT give doxycycline in pregnancy or breastfeeding)
    AND
    Metronidazole IV 500mg 8 hourly

    IVOST: 24 hours after clinical improvement.
    Doxycycline PO 100mg 12 hourly (Do NOT give doxycycline in pregnancy or breastfeeding)
    AND
    Metronidazole PO 400mg 8 hourly.
    Total duration of treatment 14 days.

    If patient is pregnant or breastfeeding
    Substitute PO Erythromycin 500mg QDS for Doxycycline in above regimen.

    In severe penicillin allergy
    Contact Medical Microbiology

    POST-OPERATIVE PYREXIA

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Post-Operative Pyrexia Various CefUROXime IV 1.5g 8 hourly
    AND
    Metronidazole IV 500mg 8 hourly

    If severe penicillin allergy
    Contact Medical Microbiology

    IVOST
    Co-amoxiclav PO 625mg TDS

    Non-severe Penicillin Allergy:
    CefACLor PO 500mg TDS
    AND
    Metronidazole PO 400mg TDS

    Severe Penicillin Allergy:
    Discuss with Microbiology
    N.B. Initial pyrexia may be related to tissue breakdown and anaesthesia. Assess for signs of sepsis. Take blood cultures, swabs, sputum & MSU where appropriate.

    GYNAECOLOGY PROPHYLAXIS

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Vaginal Hysterectomy
    Laparotomy
    Vaginal repair
    E. coli
    Streptococci
    S. aureus
    Enterococci
    Gardnerella vaginalis
    Bacteroides spp.
    Cefuroxime 1.5g IV once only
    AND
    Metronidazole 500mg IV once only

    Severe Penicillin Allergy
    Clindamycin 600mg IV once only
    AND
    Gentamicin 120mg IV once only
    History of MRSA colonisation in preceding 12 months ADD Teicoplanin 800mg IV at induction to appropriate regimen
    Suburethral Sling Coliforms Gentamicin IV 120mg once only

    SKIN AND SOFT TISSUE INFECTIONS

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Post-operative Wound Infection

    Superficial Infections
    Staph. aureus

    Haemolytic streptococci
    Flucloxacillin PO 500mg 6 hourly for 5 days

    Penicillin Allergy
    Clarithromycin PO 500mg 12 hourly for 5 days
    Where pus is present take a swab prior to treatment.

    A reddened wound does not always require antibiotics. Only use if infection is suspected or microbiologically confirmed.
    NB. Erythromycin is the macrolide of choice in pregnancy and breastfeeding.
    Serious wound Infections Associated with Gynae-cological Surgery Staph. aureus
    Streptococci
    Anaerobes
    Coliforms
    Flucloxacillin IV 2g 6 hourly
    AND
    Gentamicin IV
    AND
    Metronidazole IV 500mg 8 hourly

    Penicillin Allergy
    CefUROXime IV 1.5g 8 hourly
    AND Metronidazole IV 500mg 8 hourly
    Take blood cultures
    Where pus is present take a swab prior to treatment.
    Use microbiology results to guide therapy.
    If MRSA infection is suspected Vancomycin IV should be used as an alternative to Flucloxacillin.
    Bartholin’s Abscess Various Co-amoxiclav PO 625mg TDS

    Non-severe Penicillin Allergy:
    CefACLor PO 500mg TDS
    AND
    Metronidazole PO 400mg TDS

    Severe Penicillin Allergy:
    Discuss with Microbiology
    Drainage alone may suffice as treatment.

    Urethral and cervical swabs should be taken to check for Neisseria gonorrhoeae and chlamydia.

    TOXIC SHOCK SYNDROME

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Toxic Shock Syndrome Staph. aureus Early referral for critical care management is advised.

    Tazocin IV 4.5g 8 hourly
    AND
    Clindamycin IV 1.2g 6 hourly

    Penicillin Allergy OR Patient Pregnant
    Contact O&G Consultant and Consultant Microbiologist for advice.
    Initial symptoms and signs include myalgia, fever, diarrhoea and vomiting.

    Diagnostic manifestations include severe hypotension and an erythematous rash with conjunctival inflammation.

    Blood cultures and relevant swabs for culture (e.g. HVS, surgical wound swab) should be sent.

    URINARY TRACT INFECTION

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Uncomplicated Cystitis Coliforms Nitrofurantoin PO 100mg M/R 12 hourly if GFR > 45ml/min

    OR if nitrofurantoin contraindicated:
    Pivmecillinam PO 400mg TDS (this is a penicillin)

    In non-severe penicillin allergy:
    CefaLEXin PO 500mg TDS
    Antibiotics should not be used empirically following increased frequency or mild dysuria.

    A fresh MSU should be taken. Monitor renal function.

    Duration of therapy 3 days
    Pyelonephritis Coliforms Gentamicin IV
    OR
    CefUROXime IV 1.5g 8 hourly
    Refer to Urologists.

    Always take blood cultures and a urine specimen.
    Total duration of treatment, including appropriate IVOST is 7-10 days.
    Switch to oral antibiotics after symptoms and signs have resolved for 48 hours.
    Culture results will guide oral therapy.

    VAGINAL DISCHARGE

    Clinical Diagnosis Common pathogens Treatment advice Comments/Guidelines for lab testing
         
    Vaginal Candidiasis Candida sp. Use Clotrimazole PV 500mg pessary once only and Clotrimazole 1% cream BD-TDS for 7 days
    OR
    Fluconazole PO 150mg once only
    Seek specialist advice if recurrent or refractory to treatment.

    Always avoid Fluconazole if there is any suspicion of pregnancy
    Trichomoniasis (TV) Trichomonas vaginalis Metronidazole PO 400mg BD for 7 days
    OR
    Metronidazole PO 2g single dose
    Refer to Genito Urinary Medicine

    The patient’s partner should be treated simultaneously.
    Bacterial vaginosis Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma. Metronidazole PO 400mg BD for 7 days
    OR
    Clindamycin 2% Cream PV 5g at night for 7 nights
    Discuss refractory or recurrent cases with a Consultant Medical Microbiologist
    Infections with Chlamydia, N. gonorrhoeae, genital herpes or TV should always be referred to the Sefton Sexual Health Service on 01704 513303

    GOOD PRACTICE IN ANTIBIOTIC PRESCRIBING


    Does the child need antibiotics?
    • Is the infection bacterial or could it be viral?
    • Bacteria isolated from a specimen may represent colonisation or overgrowth NOT infection. Colonisation rarely requires systemic antibiotic therapy.

    Identifying the likely source of infection
    • It is advised that appropriate specimens are collected preferably prior to initiating empirical antibiotic therapy. Patients with signs of sepsis should have blood cultures taken. Do not delay treatment in severely ill patients whilst awaiting specimen collection.
    • Previous culture reports should be used to guide empirical therapy e.g. recent sputum samples for suspected respiratory tract infections or recent mid-stream urine (MSU) specimens for suspected urinary sepsis.
    • Also take note if the child is known to be colonised with any multi-resistant organisms e.g. Meticillin Resistant Staphylococcus aureus (MRSA).

    Selecting Antimicrobial Agents
    The Paediatric Antimicrobial Guidelines should be followed when selecting antimicrobial therapy.

    • For situations without the guidance or whenever the prescriber is uncertain, advice should be sought from a senior member of the clinical team who can discuss with a Consultant Microbiologist, as necessary.
    • When commencing empirical antibiotic therapy, ensure blood culture(s) and any other appropriate samples are taken before initiation.
    • Check for factors which will affect drug choice e.g. interactions, allergy and impaired renal function (beware of possible reduced renal function in presence of normal creatinine).
    • Check the appropriate dose is prescribed, if uncertain contact Pharmacy or check in the Children’s British National Formulary (BNFc).
    • The need for antibiotic therapy should be reviewed on a daily basis. For most infections 5-7 days is sufficient.
    • All intravenous (IV) antibiotics should be given for no more than 48 hours without review and consideration of oral alternatives.
    • IV to oral (PO) switch therapy antibiotics (IVOST) should be based upon clinical indicators such as fever defervescence for at least 24 hours, falling C-reactive protein (CRP) and marked clinical improvement. Switch to appropriate alternative agent(s) should also be made based upon microbiology results or other information.
    • Patients may be considered for suitability for the Paediatric Outpatient Parenteral Antibiotic Treatment (POPAT) service. Note that prescriptions for this service cannot be dispensed out of hours.

    Notifiable Diseases
    Note that certain infections (e.g. Meningitis, Scarlet fever, invasive Group A Streptococcal Infection etc.) require notification to Public Health England on the grounds of clinical suspicion, without laboratory confirmation. Click here for contact details for Public Health England.

    Sepsis in Children


    Age Treatment Advice Likely Organisms Comments
           
    Birth to 1 month CefoTAXime IV
    AND
    Amoxicillin IV
    Group B Streptococcus
    Escherichia coli
    Listeria monocytogenes
    Haemophilus influenzae
    Streptococcus pneumoniae
    Klebsiella spp.
    Salmonella spp.
    Staphylococcus aureus
    Enterococcus spp.
    Obtain appropriate cultures before starting antibiotic treatment as soon as possible, and always within 1 hour of presentation.

    Check previous microbiology results to determine if recent antibiotic-resistant organisms have been identified and contact Microbiology if:
  • Patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
  • Prolonged/multiple antibiotic use in the previous 3 months
  • Patient has been overseas in the previous 3 months


  • Once causative organism is known (usually within 24 hours) antibiotic choice and duration should be amended if necessary.

    Stop amoxicillin once Listeria meningitis is excluded.

    Consider stopping antibiotics if there is no growth from cultures after 36 hours.
    Over 1 month CefoTAXime IV Escherichia coli
    Haemophilus influenzae
    Streptococcus pneumoniae
    Klebsiella spp.
    Salmonella spp.
    Staphylococcus aureus
    Neisseria meningitidis

    BONE AND JOINT INFECTIONS


    Clinical Diagnosis Treatment Advice Comments
         
    Septic Arthritis / Osteomyelitis  < 3 months old
        CefoTAXime IV
        AND
       
    Flucloxacillin IV

    3 months - 5 years old
        CefUROXime IV
       

    > 5 years old
       Flucloxacillin IV
       
    If the child has sickle cell or is immuno-compromised use CefTRIAXone IV instead of Flucloxacillin

    Penicillin allergy
    Substitute Clindamycin for Flucloxacillin in the above regimes.

    Severe penicillin allergy
    Contact medical microbiology where cephalosporin is indicated.

    Most commonly caused by Staphylococcus aureus. More rarely due to Kingella kingae, haemolytic strepococci and Haemophilus influenzae < 2years, but rarely since the advent of Haemophilus influenzae type B (HiB) immunisation. Other organisms have occasionally been implicated.

    Blood cultures and joint aspirate (if appropriate) should be taken prior to therapy. Change to Flucloxacillin IV and oral Sodium Fusidate if Staphylococcus aureus infection is confirmed (assuming organism is susceptible).

    Endocarditis


    • Send at least two sets of blood cultures within a 24 hour period
    • Seek cardiology and microbiology advice

    Gastro-Intestinal tract infections

    Clinical Diagnosis Treatment Advice Comments
         
    Peritonitis CefUROXime IV
    AND
    Metronidazole IV
    Take blood cultures and pus/aspirate if appropriate.
    Gastroenteritis

    e.g. Salmonella, Shigella, Campylobacter
    Antibiotic therapy usually SHOULD BE AVOIDED

    Antibiotic therapy may be appropriate particularly if < 3 months or if there is associated bacteraemia (Salmonella, Campylobacter). Discuss with Microbiologist in such cases.

    Antibiotics must not be given if Escherichia coli 0157 infection is suspected.

    MENINGITIS

    Age Treatment Advice Comments
         
    Under 3 months old Empirical Treatment
    CefoTAXime IV
    AND
    Amoxicillin IV

    Penicillin allergy
    Contact Medical Microbiology

    Treatment of known organism
    • In confirmed Group B streptococcal meningitis treat with IV cefoTAXime for at least 14 days.

    • In confirmed bacterial meningitis due to Gram-negative bacilli treat with IV cefoTAXime for at least 21 days unless directed otherwise by the results of antibiotic sensitivities.

    • In confirmed Listeria meningitis treat with IV amoxicillin for 21 days, plus IV gentamicin for at least the first 7 days.

    • In unconfirmed but clinically suspected bacterial meningitis, treat with IV cefoTAXime plus IV amoxicillin for at least 14 days.

    If allergy status is a concern contact Medical Microbiology
    Likely organisms are:
    Group B Streptococcus
    Escherichia coli
    Listeria monocytogenes
    Neisseria meningitidis
    Haemophilus influenzae
    Streptococcus pneumoniae
    Herpes simplex virus




    If the clinical course is complicated, consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.
    3 months old and over Empirical Treatment
    CefTRIAXone IV

    Severe Penicillin allergy
    Contact Medical Microbiology

    Treatment of known organism
    • In confirmed meningococcal disease, treat with intravenous cefTRIAXone for 7 days in total unless directed otherwise by the results of antibiotic sensitivities.

    • In confirmed H influenza type B meningitis, treat with IV cefTRIAXone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.

    • In confirmed S pneumoniae meningitis, treat with IV cefTRIAXone for 14 days in total unless directed otherwise by the results of antibiotic sensitivities.

    • In unconfirmed but clinically suspected Bacterial meningitis, treat with IV ceftRIAXone for at least 10 days depending on symptoms and signs and course of the illness.

    If allergy status is a concern contact Medical Microbiology
    Likely organisms are:
    Neisseria meningitidis
    Haemophilus influenzae
    Streptococcus pneumoniae



    Consider adding dexamethasone therapy in line with NICE guidelines.

    Blood cultures should always be taken prior to therapy. A Cerebrospinal Fluid (CSF) sample should also be taken if possible.

    Take a separate EDTA (Ethylenediaminetetra-acetic Acid) sample for meningococcal polymerase chain reaction (PCR) and a throat swab for meningococcal culture if meningococcal disease is the most likely diagnosis clinically. These should be taken as soon as possible after admission since there is a significant decline in detection of Meningococci on culture and meningococcal DNA (Deoxyribonucleic acid) once antibiotics are commenced.

    Notify Consultant in Health Protection and inform Hospital Infection Prevention and Control Team (Ext 4169). Click here for Public Health England contact details.

    If viral infection is a part of the differential diagnosis, add IV aciclovir.

    When viral infection is suspected REMEMBER throat swab and faeces for enterovirus PCR.

    Viral PCR will NOT be routinely tested on CSF specimens with normal cell counts UNLESS the Consultant Paediatrician discusses the case with the Consultant Microbiologist.

    OPHTHALMIC INFECTIONS

    Clinical Diagnosis Treatment Advice Comments
         
    Purulent conjunctivitis Chloramphenicol eye ointment

    Chlamydia
    Erythromycin PO for a minimum of 2 weeks and until the symptoms have resolved.
    Most common organisms are Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae.

    If Chlamydia infection is suspected (< 9 months old) REMEMBER to take a Chlamydia swab before starting any antibiotics (seek specific instruction for this). Genitourinary Medicine (GUM) referral is advised.
    Contact Integrated Sexual Health 01704 513303

    Ophthalmology review
    may also be indicated
    Orbital/peri-orbital cellulitis 3 months old
    CefoTAXime IV

    > 3 months old
    CefTRIAXone IV

    IV to oral switch
    PO Co-amoxiclav

    Penicillin allergy
    Discuss with Microbiology
    Most common organisms include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes and Haemophilus influenza.

    Consider adding metronidazole if there is sinus disease or orbital cellulitis is suspected. Refer urgently to ENT also.

    Skin and Soft Tissue infection


    Clinical Diagnosis Treatment Advice Comments
         
    Cellulitis

    (N.B. see under ophthalmic infections for peri-orbital cellulitis)
    Mild infection
    Flucloxacillin PO

    Penicillin Allergy
    Clarithromycin PO
    OR
    Clindamycin PO

    Moderate to Severe infection
    Flucloxacillin IV

    Penicillin Allergy
    Vancomycin IV (See BNF for Children for dosing and monitoring guidance)
    Most commonly caused by Streptococcus pyogenes or Staphylococcus aureus.
    Human/ Dog/ Cat bites Co-amoxiclav PO

    Penicillin allergy
    ≥12 years old
    Doxycycline PO
    AND
    Metronidazole PO

    <12 years of age with penicillin allergy
    Azithromycin PO
    AND
    Metronidazole PO
    Infection requiring hospital admission and for other types of animal bites discuss with microbiologist.

    Consider child protection issues, particularly if child bitten by adult.
    Complex Wound Infection
    The management of these infections may involve mixed organisms
    Discuss management with Tissue Viability Nurse
    Ext. 4302 or ASCOM 3817

    Urinary tract infection


    Clinical Diagnosis Treatment Advice Comments
         
    Aged < 3 months old Treat as per community acquired sepsis guidance.
    Aged 3 months and over

    Upper urinary tract infection / pyelonephritis
    CefTRIAXone IV

    Consider adding IV Gentamicin if the patient is haemodynamically unstable, previous renal pathology or recurrent urinary tract infections.

    Severe penicillin allergy
    Contact Medical Microbiologist
    Discuss treatment with a Medical Microbiologist if the child is already taking a cephalosporin for long term prophylaxis.
    Aged 3 months and over

    Cystitis / lower urinary tract infection
    CefaLEXin PO Nitrofurantoin may be a suitable alternative in patients able to have capsules.

    Community acquired pneumonia

    Age Treatment Advice Comments
         
    Aged less than 1 month Treat as per community acquired sepsis guidance Take blood cultures prior to starting antibiotic therapy.

    Send nose and throat swabs in viral transport medium for Mycoplasma PCR.

    Oral antibiotics are as effective as IV for the treatment of severe pneumonia. IV antibiotics should only be considered in patients unable to take oral medication.

    Consider influenza and send viral swabs when indicated. See current PHE guidance on use of antivirals in treatment and prophylaxis of influenza.

    See also BTS guidance on Community Acquired Pneumonia in children for further information.
    Aged 1 month and over Mild to moderate infection
    Amoxicillin PO

    Penicillin allergy
    Clarithromycin PO


    Severe infection or infection associated with influenza

    Amoxicillin PO
    AND
    Clarithromycin PO

    Penicillin allergy
    Contact Medical Microbiology


    If suspected bacterial pneumonia is associated with influenza or measles
    Co-amoxiclav PO

    Penicillin allergy
    Contact Medical Microbiology

    Other respiratory tract infections

    Clinical Diagnosis Treatment Advice Comments
         
    Acute otitis media Amoxicillin PO

    Penicillin allergy
    Clarithromycin PO
    Most are viral. Common bacterial causes include Streptococcus pneumoniae, other streptococci & Haemophilus spp.

    Treat for 5 days
    Tonsillitis Phenoxymethylpenicillin PO

    Penicillin allergy
    Clarithromycin PO
    Most are viral. Likely bacterial causative organism is Streptococcus pyogenes. A 10 day antibiotic course is usually recommended to prevent immune complex mediated sequelae
    Peri-tonsillar abscess Co-amoxiclav IV

    Penicillin allergy
    Clindamycin IV
    Consider oral switch (IVOST) according to clinical response.
    Caused by a variety of bacteria including haemolytic Streptococci, Staph. aureus and occasionally anaerobes.

    Draining the abscess is the best treatment.
    Acute epiglottitis ≤ 3 months old
    CefoTAXime IV

    > 3 months old
    CefTRIAXone IV

    Severe penicillin allergy
    Contact Medical Microbiology
    Most common bacterial cause is Haemophilus influenzae. Other organisms have been rarely described.

    This is a notifiable condition
    Click here for Public Health England contact details.

    GOOD PRACTICE IN ANTIBIOTIC PRESCRIBING



    The threshold for an infection screen is always low. Use the following framework below to direct antibiotic management decisions. Antibiotics should always be given within 1 hour of decision to treat.

    Risk factors for early-onset neonatal infection, including ‘red flag’ factors
    • Parenteral antibiotic treatment given to the mother for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour period before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]*
    • Suspected or confirmed infection in another baby in the case of a multiple pregnancy*
    • Invasive group B streptococcal infection in a previous baby
    • Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
    • Prelabour rupture of membranes
    • Preterm birth following spontaneous labour (before 37 weeks’ gestation)
    • Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
    • Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
    * ‘Red flag’ risk factors


    Clinical indicators of possible early-onset neonatal infection (observations and events in the baby), including ‘red flags’
    • Respiratory distress starting more than 4 hours after birth*
    • Seizures*
    • Need for mechanical ventilation in a term baby*
    • Signs of shock*
    • Altered behaviour or responsiveness
    • Altered muscle tone (e.g. floppiness)
    • Feeding difficulties (e.g. feed refusal)
    • Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension
    • Abnormal heart rate (bradycardia or tachycardia)
    • Signs of respiratory distress
    • Hypoxia (e.g. central cyanosis or reduced oxygen saturation level)
    • Jaundice within 24 hours of birth
    • Apnoea
    • Signs of neonatal encephalopathy
    • Need for cardio-pulmonary resuscitation
    • Persistent foetal circulation (persistent pulmonary hypertension)
    • Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors
    • Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (INR greater than 2)
    • Oliguria persisting beyond 24 hours after birth
    • Altered glucose homeostasis (hypoglycaemia or hyperglycaemia)
    • Metabolic acidosis (base deficit of 10mmol/l or greater)
    • Local signs of infection (e.g. affecting the skin or eye)
    * ‘Red flag’ clinical indicators

    In babies with any red flags, or with 2 or more ‘non-red flag’ risk factors or clinical indicators, perform investigations and start antibiotic treatment. Do not delay starting antibiotics pending the test results

    In babies without red flags and only one risk factor or one clinical indicator, using clinical judgement, consider:
    1. Whether it is safe to withhold antibiotics, and
    2. Whether it is necessary to monitor the baby’s vital signs and clinical condition.
    If monitoring is required continue it for at least 12 hours (at 0, 1 and 2 hours then 2 hourly for 10 hours)


    Infection screening
    • Blood culture (not from arterial line unless the first sample taken after siting)
    • FBC, CRP (repeat after 24 hours, as a rise in levels may be delayed)
    • Lumbar puncture:

    If it is thought safe to do so and:
     There is a strong clinical suspicion of infection, or
     There are clinical symptoms or signs suggesting meningitis

    If performing the lumbar puncture would unduly delay starting antibiotics, perform it as soon as possible after starting the antibiotics
    • Swabs of any suspicious lesions:
     Tissued cannula sites
     Eye swabs for routine culture and chlamydia for eye discharge
    • In babies with clinical signs of umbilical infection, such as a purulent discharge or signs of periumbilical cellulitis (e.g. redness, increased skin warmth or swelling), perform a blood culture and take a swab for microscopy and culture
    • Urine microscopy or culture (suprapubic aspirate may be indicated) after 72 hours of life
    • Chest x-ray (and abdominal x-ray if NEC is suspected)
    • Remember maternal HVS if indicated (PROM, maternal pyrexia)
    • Check the appropriate dose is prescribed. If uncertain contact Pharmacy or check in the Children’s British National Formulary (BNFc).
    • Colonisation surveillance screening for all admissions to the neonatal unit
     Ear and umbilical swabs for MRSA AND routine culture


    Discontinuing antibiotics
    Consider stopping the antibiotics at 36 hours if:
    1. The blood culture is negative, and
    2. The initial clinical suspicion of infection was not strong, and
    3. The baby’s clinical condition is stable with no clinical indicators of possible infection, and
    4. The levels and trends of CRP concentration are either normal or improving

    Gastro-Intestinal Tract Infections

    Clinical Diagnosis Treatment Advice Comments
         
    Necrotising enterocolitis Benzylpenicillin IV
    AND
    Gentamicin IV
    AND
    Metronidazole IV
    Send blood cultures. Stool specimen for bacteriology and virology
    Oropharyngeal candidiasis Nystatin 100 000 units/ml oral suspension 1ml PO 6 hourly
    Perianal candidiasis Topical miconazole 2% cream 12 hourly

    Management of babies of HIV positive mothers


    See regional guidelines on management of HIV infection in pregnant women available at: https://www.liv.ac.uk/media/livacuk/instituteoftranslationalmedicine/pharmacology/hiv/MC_PERINATAL_GUIDELINES_2014_version,4,0.pdf

    Meningitis


    Clinical Diagnosis Treatment Advice Comments
         
    Neonatal meningitis Empirical therapy

    CefoTAXime IV
    AND
    Amoxicillin IV

    Culture results will inform targeted therapy

    • In confirmed Group B streptococcal meningitis treat with intravenous cefoTAXime for at least 14 days.
    • In confirmed bacterial meningitis due to Gram-negative bacilli treat with intravenous cefoTAXime for at least 21 days unless directed otherwise by the results of antibiotic sensitivities.
    • In unconfirmed but clinically suspected bacterial meningitis, treat with intravenous cefoTAXime plus intravenous amoxicillin for at least 14 days.
    If Herpes simplex meningoencephalitis is part of the differential diagnosis add IV aciclovir

    If the clinical course is complicated, consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.
    Neonatal listeria meningitis Amoxicillin IV
    AND
    Gentamicin IV
    Treat with IV amoxicillin for 21 days (plus IV gentamicin for at least the first 7 days)


    Blood cultures should always be taken prior to therapy. A CSF sample should also be taken unless there are over-riding clinical reasons not to do so.

    Neonatal Sepsis


    Clinical Diagnosis Treatment Advice Comments
         
    Neonatal sepsis Early onset infection (within 72 hours of birth)
    Benzylpenicillin IV
    AND
    Gentamicin IV

    If baby is not improving and cultures are negative after 48 hours, repeat cultures and change to IV CefoTAXime and gentamicin. If there is still no response after a further 48 hours; again repeat cultures and add IV Teicoplanin

    Late onset infection (>72 hours after birth)
    CefoTAXime IV
    AND
    Gentamicin IV

    If no improvement in 48 hours repeat cultures and add IV Teicoplanin

    If Staph aureus likely pathogen e.g. spotty baby
    Flucloxacillin IV
    AND
    Gentamicin IV
    Amoxicillin should be substituted for benzylpenicillin or added to cefoTAXime if Listeria infection is suspected in neonates e.g. if mother is febrile/unwell.

    Typically caused by Group B Streptococcus, E coli and other Gram-negative Bacilli. Staphylococcus aureus may occasionally be implicated and Listeria monocytogenes is now a rarely reported pathogen

    IV Teicoplanin Dosing and Monitoring
    Give a loading dose followed by maintenance dose according to the BNF for Children.
    Group B Streptococcal infection Benzylpenicillin IV
    AND
    Gentamicin IV
    See ICO Policy No. 54 Management of Newborns of Group B Streptococcal Infection for full guidelines)


    • Review culture results at 36 hours. If cultures are negative at 36 hours the antibiotics can be stopped unless there is definite clinical suspicion of infection. Intra-vascular lines are not a reason to continue.
    • The usual duration of antibiotic treatment for babies with a positive blood culture and those with a negative culture but in whom there has been strong suspicion of sepsis is a minimum of 7 days.
    • Continue antibiotic treatment for more than 7 days if:
    1. The baby has not yet fully recovered , or
    2. This is advisable for other reasons, based on the clinical scenario e.g. meningitis or pathogen identified on blood culture. Seek advice from Consultant Microbiologist.
    • Interpretation of blood cultures growing skin flora (coagulase negative staphylococci, diphtheroids etc) in neonates receiving intensive care (ventilation, central lines etc) is often difficult. The decision to treat with antibiotics is usually based on a clinical suspicion of infection. Remember that a significant proportion of these isolates are sensitive to first and second line regimens
    • If systemic fungal infection suspected seek advice from Consultant Microbiologist.

    Ophthalmic Infections

    Clinical Diagnosis Treatment Advice Comments
         
    Purulent conjunctivitis
    (Ophthalmia neonatorum)
    Chloramphenicol eye ointment

    Chlamydia
    Erythromycin orally for a minimum of 2 weeks and until the symptoms have resolved.

    N. gonorrhoea
    CefoTAXime IV for 7 days

    Severe Penicillin Allergy
    Contact Medical Microbiology
    If Chlamydia or N. gonorrhoeae infection is suspected send swabs for routine culture and for Chlamydia and N.gonorrhoeae PCR.

    Genitourinary Medicine referral is advised
    Contact Integrated Sexual Health on 01704 513303
    Consider Ophthalmology referral

    Varicella-zoster (VZ)


    Chickenpox prophylaxis for neonates
    Discuss with Microbiology and refer to DOH guidance
    Varicella zoster immunoglobulin (available only via discussion with Consultant Microbiologist)) is recommended for infants if:

    (i): mother develops chickenpox (but NOT shingles) from 7 days before until 7 days after delivery.
    (ii): VZ antibody negative infant has contact (other than mother) with chickenpox or shingles in first 7 days of life.
    (iii): VZ antibody negative infant of any age is exposed to chickenpox or shingles while still requiring intensive or prolonged special care nursing.

    If severe chickenpox develops in the neonate despite VZIG, high dose intravenous aciclovir treatment of 20mg/kg every eight hours for at least seven days should be started as soon as possible. Prophylactic intravenous aciclovir should also be considered for infants whose mothers develop chickenpox from four days before to two days after delivery as they are at the highest risk of fatal outcome despite VZIG prophylaxis.

    See also Public Health England guidance on Viral Rash in Pregnancy for further information: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322688/Viral_rash_in_pregnancy_guidance.pdf

    ANTIBIOTIC ASSAYS


    If advice is required contact ward clinical Pharmacist or Antimicrobial Pharmacist or Medicines Information during normal working hours or on call pharmacist via switchboard if out of hours.

    NB. When contacting pharmacy to obtain advice about antibiotic assays, please ensure you have the following information:
    • Patient’s name and date of birth
    • Clinical indication for the antibiotic
    • Dose regime for the antibiotic
    • Result of the antibiotic assay and when the assay was taken
    • Timing of the last dose in relation to the assay
    • Current renal function and weight

    VANCOMYCIN (IV)

    Note It is good practice to inform the ward Pharmacist when starting a patient on IV vancomycin.

    Follow the algorithm below with the following exclusions:
    Pregnancy - Use with caution - contact pharmacy for dosing and monitoring advice
    Paediatrics - Contact pharmacy for dosing and monitoring advice
    Renal ReplacementDiscuss with pharmacy and (if appropriate) with dialysis unit.

    Dose: An initial loading dose of vancomycin is required followed by maintenance dosing

    To improve consistency in the prescribing of vancomycin and to reduce risk use the locally agreed ‘Vancomycin Dosing Chart’ to document the prescription, administration and ongoing monitoring of vancomycin. These charts contain a step-wise approach for the safe and effective prescribing and monitoring of vancomycin together with advice on dose adjustment.

    Loading dose is determined by patient’s total body weight regardless of renal function:

    Total Body Weight (Kg.) Vancomycin loading dose
       
    ≤ 60 1.25g in 250ml sodium chloride 0.9% infused over 125 minutes
    60 - 90 1.5g in 500ml sodium chloride 0.9% infused over 150 minutes
    ≥ 90 2g in 500ml sodium chloride 0.9% infused over 200 minutes


    Maintenance dose is determined by the patient’s creatinine clearance (CrCl) which should be calculated as below. Do not use eGFR.

    Obtain the relevant patient details i.e. weight, height, age and serum creatinine.
    Calculate creatinine clearance (CrCl) using the equations below. If patient is obese i.e. Total Body Weight (TBW) is 20% greater than Ideal Body Weight for height (IBW) then use Adjusted Body Weight (ABW) to calculate creatinine clearance.

  • The following equation should be used initially to calculate Ideal Body Weight:
    IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
    IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • This equation can then be used to calculate Adjusted Body Weight:
    ABW (kg) = IBW + 0.4(TBW – IBW)

  • Then calculate creatinine clearance as follows:
    CrCl (ml/min) in males = (140 – age in years) x 1.23 x weight in kg / Serum creatinine (micromoles/l) *
    CrCl (ml/min) in females = (140 – age in years) x 1.04 x weight in kg / Serum creatinine (micromoles/l) *

  • *In patients with an abnormally low serum creatinine (i.e. < 40micromol/L) use 40micromol/L as the value used to calculate Creatinine Clearance

    CAUTIONS
     
  • 1. Spinal injuries patients: CrCl calculated as above must be corrected to account for their lower serum creatinine levels caused by reduced muscle mass and activity. Correct calculated CrCl as follows:

    Corrected CrCl in paraplegics (ml/min) = Calculated CrCl (ml/min) x 0.8
    Corrected CrCl in tetraplegics (ml/min) = Calculated CrCl (ml/min) x 0.6

  • 2: Patients with Liver Cirrhosis (Childs Pugh of C): Falsely low creatinine levels caused by reduced muscle mass and reduced hepatic creatine production.

  • 3: Patients with amputations: Falsely low creatinine levels caused by muscle loss. Contact pharmacy for advice on estimating renal function.



  • Table 1: Vancomycin maintenance dosing in patients with CrCl > 20ml/min
    CrCl ml/min Vancomycin maintenance dose Frequency*
         
    ≤ 20 Refer to Table 2.
    20 - 29 500mg 24 Hourly
    30 - 39 750mg 24 Hourly
    40 - 54 500mg 12 Hourly
    55 - 74 750mg 12 Hourly
    75 - 89 1g 12 Hourly
    90 - 110 1.25g 12 Hourly
    > 110 1.5g 12 Hourly

    *The first maintenance dose should be started after the time specified above e.g. if the dosing guide recommends a dose of 500mg 24 hourly, then the first maintenance dose should be given 24 hours after the loading dose.

    Maintenance dosing in patients with CrCl ≤ 20ml/min
    Check a level 24 hours after the loading dose. Only give a further dose as detailed in table below when the level < 15mg/L (or ≤ 20mg/L for endocarditis/other deep seated/MRSA infection or neutropenic sepsis). Continue to re-check levels at 24 hourly intervals and re-dose as above.

    Table 2: Vancomycin maintenance dosing in CrCl ≤ 20ml/min
    Actual body Weight Vancomycin maintenance dose
       
    < 50 750mg in 250ml 0.9% sodium chloride over 75 minutes
    50 - 70 1g in 250ml 0.9% sodium chloride over 120 minutes
    > 70 1.25g in 250ml 0.9% sodium chloride over 150 minutes


    Contact pharmacy for further advice if required: contact ward clinical Pharmacist or Medicines Information or Antimicrobial Pharmacist during normal working hours or on call Pharmacist via switchboard if out of hours.
    Levels:
    Post dose levels are NOT indicated.
    5ml clotted blood is required and must be taken PRE-DOSE (i.e. a trough level). State dose, time last dose given and time level was taken on request form. Label as PRE-DOSE level. Appropriate arrangements must always be made to ensure levels are taken at the correct time (including out of hours and at weekends).
    The timing of levels should be as follows:

    Patients with CrCl > 20 ml/min
    For ONCE daily dosing take a PRE-DOSE level just before the 2nd dose, then GIVE the dose.
    For TWICE daily dosing take a PRE-DOSE level just before the 3rd dose, then GIVE the dose.
    Review the result of the level before any subsequent doses are given.

    Patients with CrCl ≤ 20 ml/min:
    Refer to section above on maintenance dosing in patients with CrCl ≤ 20 ml/min.

    Therapeutic range advice (PRE-DOSE level target range)
       
    MRSA Patients Pre-dose: 15-20mg/L
    Deep seated infection (e.g. endocarditis, osteomyelitis) Pre-dose: 15-20mg/L
    Neutropenic sepsis patients Pre-dose: 15-20mg/L
    All other patients Pre-dose: 10-15mg/L (unless otherwise advised by Microbiology)


    Dose adjustment: Interpret levels using the table below. Always check that the level has been taken at the correct time (i.e. PRE-DOSE) and that all previous doses have been given as prescribed.

    Guidance on interpreting PRE-DOSE levels
    Pre-Dose level Advice
    less than 5mg/L Move up TWO dosing bands
    5-10mg/L Move up ONE dosing band
    (if target range is 15-20mg/L, move up TWO dosing bands)
    10-15mg/L Continue at current dose
    (if target range is 15-20mg/L, move up ONE dosing band)
    15-20 mg/L Continue at current dose
    (if target range is 10-15mg/L, move down ONE dosing band)
    20-25mg/L Move down ONE dosing band
    Greater than 25mg/L Omit next dose and recheck levels when next dose would have been due.


    Dosing Bands
    Maintenance dose Frequency
    Higher dose: Discuss with pharmacy
    1.5g 12 Hourly
    1.25g 12 Hourly
    1g 12 Hourly
    750mg 12 Hourly
    500mg 12 Hourly
    750mg 24 Hourly
    500mg 24 Hourly
    Lower dose: Discuss with pharmacy

    Contact pharmacy for advice on dose adjustment if needed: contact ward clinical Pharmacist or Medicines Information or Antimicrobial Pharmacist during normal working hours or on call Pharmacist via switchboard if out of hours.

    Further monitoring:
    Re-check PRE-DOSE level after 24 hours if any dose change is made.
    If no dose adjustment is needed PRE-DOSE level should be re-checked after 48 hours.
    Once the levels are stable, subsequent levels should be taken every 2-3 days or more frequently if patient has renal impairment or variable renal function

    Teicoplanin


    The following advice applies to the use of teicoplanin for treatment of infection. For the use of teicoplanin in pre-operative prophylaxis, only a single dose of 800mg IV given at induction is indicated.

    IV Teicoplanin should be initially dosed based on the patient’s total body weight:
    Recommended dose
    Loading dose: 12mg/kg every 12 hours for 4 doses
    THEN
    12mg/kg every 24 hours
    Ongoing doses to be adjusted based on levels
    Note – Doses MUST be rounded to nearest 200mg


    Dose adjustment in renal impairment:
    In renal impairment a reduction in dose is not required for the first 3 days (initiate dose reduction from day 4)

    Creatinine clearance (ml/min) Dose reduction
       
    greater than 50 Dose as in normal renal function
    30 - 50 Give normal dose every 2nd day (48hours)
    less than 30 Give normal dose every 3rd day (72 hours)

    Monitoring levels:
    Serum concentration monitoring is required in patients who are on treatment for severe/deep seated infections such as deep seated staphylococcal infection (including bone and joint infection) or those who have abnormal renal function.
    Pharmacy and Medical Microbiology can advise on when to take levels and then on subsequent dose adjustment if needed. In general a level should be checked PRE-DOSE on day 7 of treatment. Levels are sent away for processing and results are usually available 2-3 days after sending the bloods. Treatment should be continued whilst awaiting the result unless advised otherwise.

    Take 5mls clotted blood immediately BEFORE giving the dose (i.e. a trough level). State dose, time last dose given and time level was taken on request form. Label as PRE-DOSE level.
    Therapeutic range
       
    Deep seated infections Pre-dose level >20mg/L but <60mg/L
    Infective Endocarditis: Pre-dose level >30mg/L but <60mg/L
    Other infections Pre-dose level >15mg/L but <60mg/L

    Further monitoring: PRE-DOSE levels should be repeated every 1-2 weeks, more frequent monitoring is not usually required.

    Adjust dose or dosage interval accordingly: Contact pharmacy for advice on dose adjustment if needed: contact ward clinical Pharmacist or Medicines Information or Antimicrobial Pharmacist during normal working hours or on call Pharmacist via switchboard if out of hours.

    Antibiotic Dosing in Renal Impairment

    Creatinine clearance (CrCl) rather than eGFR must be used for the determination of dose adjustment in renal impairment in adults. Patients that are oligoanuric (dialysis dependency/acute kidney injury) should be assumed to have a CrCl of <10 ml/min.

    Determine creatinine clearance first then refer to the table below to select the appropriate dose.

    Antibiotic

    (class of antibiotic)

    Dose in renal impairment (GFR mL/min)

    Comments

    Mild (20-50)

    Moderate (10-20)

    Severe (<10)

    Amoxicillin 1

    (penicillin)

    Dose as in normal renal function

    250mg to 1g

    every 8 hrs *

    * Up to 6g/day can be used in

    the treatment of endocarditis

    Benzylpenicillin 1

    (penicillin)

    Dose as in normal renal function

    600mg to 2.4g every 6 hours (depending on severity of infection)

    600mg to 1.2g every 6 hours (depending on severity of infection)

    Increased incidence of seizures in renal impairment.

    Can cause hypokalaemia at high doses

    CefaCLOR 1

    (cephalosporin)

    Dose as in normal renal function

    250mg every 8 hrs

     

    CefaLEXin 1

    (cephalosporin)

    Dose as in normal renal function

    500mg every 8-12 hrs

    250-500mg every 8-12 hrs

    Use dose for normal renal function to treat UTI in end stage renal failure.

    CefOTAXime 1

    (cephalosporin)

    Dose as in normal renal function

    GFR < 10mL/min 1g every 8-12 hrs

    Do not alter frequency

    Reduce dose further if there is concurrent hepatic failure.

    CefTAZidime 2

    (cephalosporin)

    GFR 31-50mL/min

    1g every 12 hrs

    GFR 6-15mL/min

    500mg every 24 hrs

    GFR <5mL/min

    500mg every 48 hrs

     

    GFR 16-30mL/min

    1g every 24 hrs

    CefTRIAXone 1

    (cephalosporin)

    Dose as in normal renal function*

    *Suggest max 2g daily in severe renal impairment

    CefUROXime IV/IM 1

    (cephalosporin)

    750mg-1.5g every 8 hrs

    750mg-1.5g every 8-12 hrs

    750mg-1.5g every 12-24 hrs

     

    Ciprofloxacin 1

    (quinolone)

    Dose as in normal renal function

    50-100% of dose

    50% of normal dose

    *Potential for hazardous drug interactions. Check drug kardex

    Clarithromycin IV 1

    (macrolide)

    Dose as in normal renal function

    250-500mg every 12 hrs

    250mg-500mg every 12 hrs

    *Potential for hazardous drug interactions. Check drug kardex

    Clarithromycin PO 1

    (macrolide)

    GFR>30mL/min

    Dose as in normal renal function

    GFR 10-30ML/min

    250- 500mg every 12 hrs

    GFR<10mL/min

    250mg-500mg every 12 hrs

    *Potential for hazardous drug interactions. Check drug kardex

    Clindamycin 1

    (lincosamide)

    Dose as in normal renal function

    Dose may require reduction with severe renal impairment due to prolonged half life

    Periodic renal & LFT monitoring during prolonged course.

    Co-amoxiclav PO 2

    (penicillin)

    GFR<30mL/min

    375mg to 625mg TWICE daily

    375mg to 625mg ONCE daily

     

    Co-amoxiclav IV2

    (penicillin)

    GFR 10-30mL/min

    1.2g stat then 600mg every 12 hrs

    GFR <10mL/min

    1.2g stat followed by 600mg every 24 hrs

     

    Doxycycline 1,2

    (tetracycline)

    Dose as in normal renal function

     

    Ertapenem 1

    (carbapenem)

    GFR>30mL/min:

    Dose as in normal renal function

    GFR 10-30mL/min: No manufacturer information. 50-

    100% of normal dose

    GFR <10mL/min: No manufacturer information. 50% of dose or 1g three times a WEEK is suggested in renal drug handbook

    Flucloxacillin 1

    (penicillin)

    Dose as in normal renal function

    Dose as in normal renal function up to total daily dose of 4g

     

    Fusidic acid / Sodium Fusidate 1,2

    (fusidane)

    Dose as in normal renal function

     

    Gentamicin

    (aminoglycoside)

    Contact Your ward Pharmacist / Medicines Information (ext 1565) / or on-call pharmacist out of hours via switch

    Linezolid 1

    (oxazolidinone)

    Dose as in normal renal function

    Dose as in normal renal function but monitor closely

    Two metabolites accumulate in renal failure which have MAOI activity but no antibacterial activity. Therefore monitor closely.

    Meropenem 1

    (carbapenem)

    500mg - 2g

    every 12 hrs

    500mg-1g every

    12 hrs or 500mg every 8hrs

    500mg-1g every

    24 hrs

     

    Metronidazole1

    (nitroimidazole)

    Dose as in normal renal function

    Active metabolites accumulate in renal impairment. Rare drug induced lupus

    Nitrofurantoin 2

    (nitrofuran)

    GFR >30 ml/min

    Does as normal in renal function
    however see comments

    Contraindicated if GFR <30 ml/min

    Note if GFR <60mL/min use with caution increased risk of treatment failure and side effects due to inadequate urine concentration & higher plasma concentration

    Phenoxymethyl penicillin (Pen V) 1,2

    (penicillin)

    Dose as in normal renal function

     

    Pivmecillinam 1,2

    (penicillin)

    Dose as in normal renal function

     

    Rifampicin 1

    (rifamycin)

    Dose as in normal renal function

    50-100% of normal dose

    *Potential for hazardous drug interactions. Check drug kardex

    Tazocin 1

    (penicillin)

    (Piperacillin / tazobactam)

    Dose as in normal renal function

    If GFR <20ml/min 4.5g every 12 hrs

     

    Teicoplanin

    (glycopeptide)

    Contact Your ward Pharmacist / Medicines Information (ext 1565) / or on-call pharmacist via switch

    Trimethoprim 2

    (sulphonamide)

    GFR >25

    Dose as in normal renal function

    GFR 15-25

    Normal for 3 days then 50% of dose

    GFR <15

    50% of normal dose

    Note: Can cause hyperkalaemia.

    Consider alternative antibiotic for UTI if GFR<15mL/min as unlikely to be effective.

    Vancomycin

    (glycopeptide)

    Contact Your ward Pharmacist / Medicines Information (ext 1565) / or on-call pharmacist out of hours via switch

    Please note, all dosage recommendations are based on GFR and not eGFR. GFR can be calculated as below.

    Calculation of Creatinine Clearance: Where F = 1.04 (females) or 1.23 (males) GFR (mL/min) = (F x (140 – age) x Ideal Body Weight (Kg)) ÷ Serum creatinine (mcmol/L)

    References

    1. The Renal Drug Handbook, 3rd edition, Radcliffe medical press, 2009

    2. Individual product monographs accessed at http://emc.medicines.org.uk/

    NB: Individual product recommendations may vary between references 1 and 2.

    CREATININE CLEARANCE CALCULATIONS

    Obtain the relevant patient details i.e. weight, height, age and serum creatinine.

    Calculate creatinine clearance (CrCl) using the equations below. If patient is obese i.e. Total Body Weight (TBW) is 20% greater than Ideal Body Weight for height (IBW) then use Adjusted Body Weight (ABW) to calculate creatinine clearance.

  • The following equation should be used initially to calculate Ideal Body Weight:
    IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
    IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • This equation can then be used to calculate Adjusted Body Weight:
    ABW (kg) = IBW + 0.4(TBW – IBW)

  • Then calculate creatinine clearance as follows:
    CrCl (ml/min) in males = (140 – age in years) x 1.23 x weight in kg / Serum creatinine (micromoles/l) *
    CrCl (ml/min) in females = (140 – age in years) x 1.04 x weight in kg / Serum creatinine (micromoles/l) *

  • *In patients with an abnormally low serum creatinine (i.e. < 40micromol/L) use 40micromol/L as the value used to calculate Creatinine Clearance


    CAUTIONS
     
  • 1. Spinal injuries patients: CrCl calculated as above must be corrected to account for their lower serum creatinine levels caused by reduced muscle mass and activity. Correct calculated CrCl as follows:

    Corrected CrCl in paraplegics (ml/min) = Calculated CrCl (ml/min) x 0.8
    Corrected CrCl in tetraplegics (ml/min) = Calculated CrCl (ml/min) x 0.6

  • 2: Patients with Liver Cirrhosis (Childs Pugh of C): Falsely low creatinine levels caused by reduced muscle mass and reduced hepatic creatine production.

  • 3: Patients with amputations: Falsely low creatinine levels caused by muscle loss. Contact pharmacy for advice on estimating renal function.

  • 4: Children and Pregnant Women: Calculation is not validated in these patient groups.
  • SELECTING THE APPROPRIATE GENTAMICIN REGIMEN

    Patient’s requiring treatment with IV gentamicin should have it prescribed and monitored as per the extended interval dosing protocol described in Regimen 1 unless any of the following exclusions apply:

    Exclusion to regimen 1 Advice
       
    Pregnancy and post-partum Use Regimen 4 – Pregnant and Post-Partum Patients
    Spinal injuries ward Use Regimen 2 – Spinal Injuries Patients
    Creatinine clearance (CrCl) of < 20ml/min

    Note: If serum creatinine is not yet known (e.g. in the Emergency Department) then Regimen 1 may still be initiated pending the U+Es unless there is evidence of existing severe renal impairment (e.g. known stage 4-5 chronic kidney disease). CrCl must still be calculated once U+Es are available.
  • Increased risk of toxicity. Use an alternative antibiotic if possible – contact microbiology to discuss
  • Recommended dose is 2.5mg/kg (max dose 200mg). Use Ideal Body Weight for height (IBW) unless Total Body Weight (TBW) is lower. If patient is obese (TBW is > 20% greater than IBW) then use Adjusted Body Weight (ABW) to calculate gentamicin dose
  • Prescribe one dose at a time and review treatment the following day
  • Check levels 24 hours post dose and await the result before giving further doses. Do not re-dose until a clearance level of < 1mg/L is achieved
  • Do not give for longer than 5 days without discussing with Medical Microbiology
  • Patients taking high dose furosemide (250mg per day or greater)
    Children (< 18 years of age) Use Regimen 5 – Paediatrics and Neonates

    Gentamicin is not the preferred agent in cystic fibrosis
    Cystic fibrosis
    Patients with > 20% burns Contact Pharmacy for dosing and monitoring advice
    Patients with significant ascites
    Patients on Haemodialysis or Peritoneal dialysis Only use gentamicin if there is no alternative – discuss with Microbiology.

    If gentamicin is essential contact pharmacy and patient’s dialysis unit to discuss a regimen
    Patients on Critical Care See separate IV gentamicin guidance in the ward drug file on the Critical Care unit
    Infective Endocarditis (or other indication requiring gram positive synergy) Use Regimen 3 – Endocarditis
    Once only ‘stat’ or prophylaxis doses

    Levels not usually required (unless further doses are given)

    If being used for surgical prophylaxis, give dose advised in prophylaxis section

    REGIMEN 1: Extended interval gentamicin dosing protocol


    Before proceeding check if one of the following exclusions applies
       
    -Pregnancy and post-partum -Severe Burns (>20% burns)
    -Spinal Injuries -Significant Ascites
    -Creatinine Clearance <20ml/min -Cystic Fibrosis
    -Paediatrics -Patients taking >250mg furosemide daily
    -Renal Replacement -Infective Endocarditis
    -Once only / prophylaxis dose -Critical Care unit
    see section on managing exclusions for guidance

    Dose:
    The Extended Interval Gentamicin Dose Calculator on the Trust Intranet can be used to calculate the appropriate gentamicin dose and the Creatinine Clearance for your patient.

    Alternatively the dose and Creatinine Clearance can be calculated manually:

    Gentamicin dose: 5mg/kg
    Round dose to the nearest 20mg
    Never give doses higher than 500mg

    Use Ideal Body Weight (IBW) to calculate the dose unless:
    Patient is obese (Total body Weight (TBW) is ≥ 20% above IBW). Then use Adjusted Body Weight (ABW) to calculate the dose.
    Patient is underweight (TBW is less than IBW). Then use TBW to calculate the dose.
  • IBW (male) = 50Kg + (2.3 x inches over 5 feet)
  • IBW (female) = 45.5Kg + (2.3 x inches over 5 feet)

  • This equation can then be used to calculate Adjusted Body Weight:
  • ABW = IBW + 0.4(TBW – IBW)

  • Prescribing
    To improve consistency in the prescribing of gentamicin and to reduce risk use the locally agreed ‘Gentamicin Prescribing and Monitoring Drug Chart’ to document the prescription, administration and ongoing monitoring of gentamicin. The chart outlines a step-wise approach for the safe and effective prescribing and monitoring of gentamicin.

    Prescribe the first dose only. Further doses to be prescribed based on the level result.

    The prescriber must specify a time for the level to be taken and ensure appropriate lab request forms are completed. The level should be taken at a convenient time within the 6-14 hour post-dose time frame, ideally during normal working hours. Appropriate arrangements must always be made to ensure levels are taken at the correct time (including out of hours and at weekends).

    Monitoring levels
    Draw a sample (5mls of clotted blood) at the time specified by the prescriber (must be 6-14 hours post dose). Record the time last dose was given and time level was taken on the Lab request form and the drug chart.

    Interpret the result of the level using the Barnes-Jewish extended interval nomogram and prescribe the next dose accordingly. If the level falls near a borderline between two intervals then the longer interval should be selected. Only the dosing interval should be adjusted, the dose itself should remain the same.

    Barnes-Jewish nomogram – for determination of dosage interval for 5mg/kg doses of gentamicin



  • 24 hourly = Prescribe the next dose to be given 24 hours after last dose was given
  • 36 hourly = Prescribe the next dose to be given 36 hours after last dose was given
  • 48 hourly = Prescribe the next dose to be given 48 hours after last dose was given.
  • Above 48 hourly range = Do not prescribe another dose. Re-check level the next day and only give another dose when level is < 1mg/L. Consider alternative antimicrobial treatment. Contact Medical Microbiology for advice on alternative antibiotics.

  • Prescriber must continue to specify an appropriate time for levels to be taken 6-14 hours after each dose and the following dose must only be prescribed once levels have been checked and interpreted as described above.
    Contact pharmacy if advice on levels is needed.

    Course should not exceed 5 days without discussion with Medical Microbiology.

    REGIMEN 2: Reduced dose regimen for use on Spinal Injuries Ward

    Usual Dose: Gentamicin 3mg/kg (round dose to the nearest 20mg) every 24 hours.

    Use Ideal Body Weight for height (IBW) unless Total Body Weight (TBW) is lower. If patient is obese (TBW is > 20% greater than IBW) then use Adjusted Body Weight (ABW) to calculate gentamicin dose:

    The following equation should be used initially to calculate Ideal Body Weight:
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)


  • This equation can then be used to calculate Adjusted Body Weight:
  • ABW (kg) = IBW + 0.4(TBW – IBW)

  • Monitoring levels
    Levels must be checked 18-24 hours post dose every day.

    The next dose must be held until the level is known to be safe.

    Appropriate arrangements must always be made to ensure levels are taken at the correct time (including out of hours and at weekends).

    Draw a sample (5mls of clotted blood) 18-24 hours post dose. The time the last dose was given and time the level was taken must be documented on the Lab request form and the drug chart. Await the result before administering the next dose of gentamicin.

    Do not take a level sooner than 18 hours post dose as the result will be misleading

  • Level < 1mg/L = The next dose may be given 24 hours after the last dose was given.
  • Level ≥ 1mg/L = Do not give the next dose. Take a further level and only re-dose when level of < 1mg/L is achieved. Contact pharmacy for advice if needed. If level is very high, consider alternative antimicrobial treatment – contact Microbiology for advice on alternative treatment.


  • Further monitoring
    Repeat levels 18-24 hours post dose after every dose. Interpret result of the level as described above.

    Course should not exceed 5 days without discussion with Medical Microbiology.

    REGIMEN 3: Endocarditis (gram positive synergy) regimen

    Obtain the relevant patient details i.e. weight, height, age and serum creatinine.
    Dose must be calculated on the basis of Creatinine Clearance (CrCl).

  • CrCl >30ml/min starting dose of gentamicin = 1 mg/kg 12 hourly
  • CrCl 10-30ml/min starting dose of gentamicin = 1 mg/kg 24 hourly
  • Round the dose to the nearest 20mg.

    If patient is obese i.e Total body Weight (TBW) is 20% greater than Ideal body Weight (IBW) then use Adjusted Body Weight (ABW) to calculate gentamicin dose:

    The following equation should be used initially to calculate Ideal Body Weight:
  • IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
  • IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

  • This equation can then be used to calculate Adjusted Body Weight:
  • ABW (kg) = IBW + 0.4(TBW – IBW)

  • Monitoring levels
    Check levels 48 hours after starting gentamicin. Timing of levels should be as follows
    Pre-dose – immediately prior to dose - then give the dose
    Post-dose – 1 hour after dose
    The dosing regimen should be timed to allow levels to be checked during normal working hours. Appropriate arrangements must always be made to ensure levels are taken at the correct times (including at weekends).
    Record time levels are taken on the drug chart and lab request form (specimens must be clearly labelled as pre or post dose).

    Desired therapeutic range
    Pre dose < 1 mg/L
    Post dose 3-5 mg/L
    In general, a high pre dose level requires an extension of the interval between doses and an abnormal post dose level requires adjustment of the dose itself. Contact pharmacy for advice on dose adjustment if needed.
    Once stable, pre dose levels should be taken every 2 to 3 days if the patient has normal renal function. There is no need to continue checking post dose levels. For patients with abnormal renal function, more frequent monitoring may be required.

    Contact Microbiology to discuss duration of therapy

    IV GENTAMICIN USE IN PREGNANT AND POST-PARTUM PATIENTS

    Monitor U+Es daily and counsel patients to report hearing or balance problems

    Dosing in pregnant / intrapartum patinetsNote Gentamicin use in pregnancy should be avoided unless considered essential. Contact Microbiology to discuss.
    Dose: 5mg/kg (upper limit of 400mg) once daily based on the patient’s recorded booking weight. Round calculated dose to the nearest 20mg. Contact pharmacy for help if needed.


    Dosing in post-partum patients:
    Dose: 5mg/kg (upper limit of 400mg) once daily. Round calculated dose to the nearest 20mg. Contact pharmacy for help if needed.



    Discuss need for further gentamicin with a senior Obstetrician or Microbiologist

    If further doses are needed levels must be checked prior to giving next dose

    Monitoring for both pregnant and post-partum patients:
    Take a level (clotted blood) 18-24 hours post first dose. Do not take the level sooner than this as the result will be misleading. Hold the second dose until the result of the level is known to be safe.

  • Level < 1mg/L = Safe level – current dose may be continued at a 24 hour interval
  • Level ≥ 1mg/L = Stop Gentamicin. Re-check level and only re-dose when < 1mg/L. Contact pharmacy for advice if needed.


  • Further monitoring:
    Take a pre-dose level (clotted blood) immediately before each subsequent dose is due. The dose may then be given immediately provided previous levels have been safe and renal function is stable. If renal impairment is known or suspected then await the result before giving the next dose.
  • Level < 1mg/L = Continue current dose and interval
  • Level ≥ 1mg/L = Check levels again before giving any further doses. Only re-dose when level is known to be < 1mg/ml. Contact Pharmacy for advice if needed.

  • Courses of IV Gentamicin should not continue beyond 5 days without advice from Medical Microbiology

    IV GENTAMICIN PRESCRIBING AND MONITORING IN CHILDREN AND NEONATES

    Dose
    0-28 days old: 5mg/kg every 36 hours
    The dosing interval may be shortened based on clinical judgement e.g. baby appears very ill
    Prescribe using the 24 hour clock format. Always block off unused timeslots on the prescription when writing the initial prescription to prevent wrong time dosing

    1 month- 18 years old: 7mg/kg every 24 hours

    Coloured aprons should be worn when preparing, checking and administering gentamicin to indicate to others that you must not be disturbed at that time.

    Always have 2 people to double-check the preparation and administration using the double-check prompt. The dose should be given within an hour of the prescribed time

    Monitoring
    Pre-dose (‘trough’) concentration
    Take blood immediately prior to every 2nd dose or more frequently if necessary. It should be less than 2mg/L. If the course of gentamicin lasts more than three doses a trough concentration of less than 1mg/L is advised

    If trough levels are unavailable, do not withhold next dose unless there is evidence of renal dysfunction

    Peak blood concentrations

    Consider taking blood 1 hour after dose in babies with:
  • Oedema
  • Macrosomia (birth weight more than 4.5kg)
  • An unsatisfactory response to treatment
  • Proven Gram-negative infection
  • If a baby has a Gram-negative or staphylcoccal infection, consider increasing the dose if peak concentration is less than 8mg/L

    Extended Interval Amikacin Dosing and Monitoring Protocol

    Amikacin should only be prescribed to a patient on the basis of Microbiology advice or culture results

    AVOID following this guidance in:

  • Pregnant women
  • Ascites
  • Severe burns
  • Renal replacement (e.g. dialysis)
  • Cystic fibrosis
  • Paediatrics
  • Patient previously received cumulative dose of 15g amikacin
  • Amikacin is contraindicated in myasthenia gravis

  • Cautions

  • Amikacin is potentially nephrotoxic and ototoxic. Urea and electrolytes must be monitored daily and the patient must be counselled on the potential for toxicity and the need to report any tinnitus, dizziness or oscillating vision immediately. If signs of toxicity develop contact Microbiology to discuss immediately and ensure a yellow card report is completed.
  • Treatment should not continue beyond 5 days without explicit Microbiology advice. If a course length of longer than 5 days is anticipated, baseline audiometry should be measured and continually assessed through treatment.
  • The maximum cumulative dose of amikacin is 15g over the lifetime of the patient.

  • Prescribing Amikacin

    1: Gather the information you need: Gender, age, weight, height and serum creatinine

    2: Calculate the patient’s Creatinine Clearance (CrCl) using the Cockcroft and Gault equation:


    CrCl (ml/min) in males = (140 – age in years) x 1.23 x weight* in kg / Serum creatinine (micromoles/l)**
    CrCl (ml/min) in females = (140 – age in years) x 1.04 x weight* in kg / Serum creatinine (micromoles/l)**

    *If patient is obese i.e. their Total Body Weight (TBW) is greater than 120% of their Ideal Body Weight (IBW) then Adjusted Body Weight (ABW) should be used to calculate CrCl:
    ABW = IBW + 0.4(TBW – IBW)
    N.B.
    IBW = 50 + (2.3 x inches over 5 feet in height) in Men
    IBW = 45.5 + (2.3 x inches over 5 feet in height) in Women

    **If serum creatinine is abnormally low (less than 40micromol/L) then use 40micromol/L in this calculation

    3: Select the dose on the basis of height and Total Body Weight using Table 1 for Male patients or Table 2 for Female patients

    4: Select the dosing frequency on the basis of the calculated Creatinine Clearance using Table 3 (AVOID using eGFR). Note that adjusted dosing frequency bands are given for patients with spinal injury to allow for reduced creatinine production

    Table 1: Amikacin doses for Men based on height and Total Body Weight
    Height /
    Weight
    under 5'1” (under 155cm)5'1” to 5'3” (155-162cm)5'4” to 5'6” (163-169cm)5'7” to 5'9” (170-177cm)5'10” to 6'0” (178-185cm)over 6'0” (over 185cm)
    under 42kg500mg500mg500mg500mg500mg500mg
    42-58kg750mg750mg750mg750mg750mg750mg
    59-75kg750mg1000mg1000mg1000mg1000mg1000mg
    76-92kg1000mg1000mg1000mg1000mg1250mg1250mg
    93-108kg1000mg1000mg1250mg1250mg1250mg1250mg
    over 108kg1250mg1250mg1250mg1250mg1500mg1500mg
    Table 2: Amikacin doses for Women based on height and Total Body Weight
    Height /
    Weight
    under 5'1” (under 155cm)5'1” to 5'3” (155-162cm)5'4” to 5'6” (163-169cm)5'7” to 5'9” (170-177cm)5'10” to 6'0” (178-185cm)over 6'0” (over 185cm)
    under 42kg500mg500mg500mg500mg500mg500mg
    42-58kg750mg750mg750mg750mg750mg750mg
    59-75kg750mg750mg750mg1000mg1000mg1000mg
    76-92kg1000mg1000mg1000mg1000mg1000mg1250mg
    93-108kg1000mg1000mg1000mg1250mg1250mg1250mg
    over 108kg1000mg1250mg1250mg1250mg1250mg1500mg

    Table 3: Dose frequency bands based on Creatinine Clearance (CrCl) AVOID using eGFR
    General patientsParaplegic patientsTetraplegic patients
    CrClFrequencyCrClFrequencyCrClFrequency
    Over 60ml/min24 hourlyOver 75ml/min24 hourlyOver 100ml/min24 hourly
    40-59ml/min36 hourly51-74ml/min36 hourly66-100ml/min36 hourly
    20-39ml/min48 hourly25-50ml/min48 hourly35-65ml/min48 hourly
    Under 20ml/minSingle dose onlyUnder 25ml/minSingle dose onlyUnder 35ml/minSingle dose only


    Monitoring

  • Monitor urea and electrolytes daily and adjust the dosing frequency according to creatinine clearance if needed. Discuss with Microbiology if acute kidney injury develops whilst on amikacin.
  • Document the exact time each dose is given
  • Take a trough (pre-dose) level at the second dose, then at least twice per week (more often if renal function unstable)
  • Draw a serum sample immediately before the dose is given using a dedicated sample of blood and document the exact time the level was drawn
  • The dose should then be given when due without awaiting the result of the level
  • Levels are sent to a reference lab and take at least 24 hours to process
  • Target trough level is less than 5mg/L. Contact Pharmacy for help with dose adjustment if needed.
  • ARK-Hospital prescription chart


    The initial antibiotic prescription should be used when initiating empirical antibiotic therapy. The documentation should be completed in full at the time of prescribing and the certainty of the diagnosis of infection should be assigned as either 'possible' or 'probable'. This is to ensure that others involved in the patient's care have as much information as possible when reviewing the antibiotic therapy. Initial antibiotic prescriptions last for a maximum of 72 hours meaning that the initial therapy must be reviewed and revised within this time and a descision made to either stop antibiotics, IV to oral switch, switch to a different antibiotic, continue current therapy or plan for OPAT.

    The finalised antibiotic prescription should be used after the initial therapy is reviewed and a final choice of ongoing therapy is made.


    ARK-Hospital decision aid flowchart


    This flowchart described the process for initiation, review and ongoing antibiotic therapy according to ARK-Hospital.


    ARK-Hospital patient leaflet


    This leaflet should be offered to patients who are prescribed antibiotics. It explains the ARK-Hospital process and how it works. A printable version of the leaflet is available via the ARK page on the Trust Intranet


    ANTIBIOTIC ALLERGY


    Antibiotics are associated with anaphylaxis. This can be a life threatening event.

    Parental administration and atopic status are more frequently associated with clinically significant events. Rapid intravenous administration is the most likely to produce such a reaction.

    Before Drug Administration:
    Enquire about previous allergy. Do not ignore what the patient says. If the patient is unclear about the nature of ‘allergy’, review previous medical records and/or discuss with patient’s GP/family/carer.

    PENICILLIN ALLERGY

    Between 0.5% and 6.5% of patients who are allergic to penicillin will also be allergic to cephalosporins. If the allergic reaction to penicillin is non-severe e.g. minor rash or delayed rash (>72 hours after administration), cephalosporins or meropenem can be given. If the allergic reaction is severe e.g. anaphylaxis, urticaria, or rash immediately after penicillin administration, cephalosporins and meropenem must be avoided unless there is clear evidence that the patient can have them safely (e.g. received cefaLEXin from their GP without any reaction).
    Note that co-amoxiclav (Augmentin®), pivmecillinam, temocillin and piperacillin-tazobactam (Tazocin®) are penicillin-based.

    Some patients who are allergic to penicillin will also be allergic to meropenem. If the patient has a history of anaphylactic reaction to penicillin, but no alternative antibiotics are available, meropenem can be used with caution (patient under careful observation with team ready to treat anaphylaxis, should it occur). If an allergic reaction to meropenem occurs, the drug should be discontinued and an alternative discussed with microbiology.

    Agents contraindicated in non-severe or severe penicillin allergy (this is not an exhaustive list):
    • Amoxicillin
    • Benzathine penicillin
    • Co-amoxiclav (Augmentin®)
    • Flucloxacillin
    • Penicillin G/Penicillin V
    • Piperacillin and tazobactam (Tazocin®)
    • Ticarcillin and clavulanic acid (Timentin®)
    • Pivmecillinam
    • Temocillin


    Agents that can be used with caution in patients with non-severe penicillin allergy (i.e. do not use if history of anaphylaxis, urticaria, or rash immediately after penicillin administration, unless discussed with Microbiology, in the event there are no alternative agents):
    • Aztreonam
    • CefaCLOR
    • CefaLEXin
    • CefoTAXime
    • CefTAZidime
    • CefTRIAXone
    • CefUROXime
    • Imipenem
    • Meropenem
    • Ertapenem


    Agents that can be used safely in patients with non-severe or severe penicillin allergy:
    • Amikacin
    • Azithromycin
    • Chloramphenicol
    • Colistin
    • Co-trimoxazole
    • Erythromycin/clarithromycin
    • Ciprofloxacin
    • Clindamycin
    • Daptomycin
    • Doxycycline
    • Gentamicin
    • Linezolid
    • Metronidazole
    • Moxifloxacin
    • Nitrofurantoin
    • Ofloxacin
    • Rifampicin
    • Sodium fusidate
    • Teicoplanin
    • Tigecycline
    • Tobramycin
    • Trimethoprim
    • Vancomycin

    ANTIBIOTICS AND CLOSTRIDIUM DIFFICILE INFECTION (CDI)


    ALL antibiotics and proton pump inhibitors can predispose the patient to CDI.



    This biohazard symbol is used throughout this guideline to alert users to antibiotic regimens that are considered high risk for causing CDI. High risk treatment should be avoided in patients who are themselves at high risk of developing CDI (see list of patient risk factors below). Alternative lower risk treatment should be given instead, discuss with Microbiology where there is no clear course of action.


    High risk antibiotics include:
    • Clindamycin;
    • Fluoroquinolones (ciprofloxacin, norfloxacin, moxifloxacin);
    • Cephalosporins (cefUROXime, cefaCLOR cefaLEXin, cefTAZidime, cefoTAXime, cefTRIAXone);
    • Co-amoxiclav (Augmentin®)


    Medium risk antibiotics include:
    • Carbapenems (meropenem, ertapenem)
    • Piperacillin-tazobactam (Tazocin®)
    • Clarithromycin/Erythromycin
    • Amoxicillin


    Lower risk (NOT no risk) antibiotics include:
    • Gentamicin
    • Penicillin
    • Flucloxacillin
    • Nitrofurantoin
    • Metronidazole
    • Trimethoprim
    • Tetracyclines e.g. doxycycline
    • Vancomycin
    • Teicoplanin


    ▪ Try to use narrow spectrum antibiotics for the shortest effective duration.
    ▪ De-escalate broad spectrum treatment as soon as culture and sensitivity data is available.
    ▪ Surgical prophylaxis must NOT be continued for more than 24hours. Single doses are sufficient for most procedures.
    ▪ Avoid the use of proton pump inhibitors unless there is a clear clinical indication.
    (See National Institute for Health and Clinical Excellence, Clinical Guideline 184: Dyspepsia and gastro-oesophageal reflux disease, 2014)

    Certain patient groups are more at risk of developing C. difficile infection.
    Known risk factors:
    • Frail elderly
    • Immunocompromised
    • Known previous C.difficile infection
    • Known previous C.difficile antigen positive stools
    • Current loose stools
    • Previous recent antibiotic treatment (particularly with high C.difficile risk agents)
    • Prolonged hospital admission
    • Nursing home resident
    • Taking a proton pump inhibitor
    • Inflammatory bowel disease
    • Alcoholism
    • Tube fed

    Where possible, high C. difficile risk patients should not be prescribed high C. difficile risk antimicrobials.

    DURATION OF TREATMENT


    Most infections e.g. pneumonia, cellulitis respond to 7 days of antibiotics.

    Some Exceptions:

    Cystitis (female): 3 days (unless pregnant)
    Streptococcal pharyngitis/tonsillitis: 5-10 days (if treated with penicillin v; only 5 days is required if treated with clarithromycin)
    Endocarditis: 2-6 weeks
    Pyelonephritis: 7-10 days
    Osteomyelitis: Several weeks/months
    Septic arthritis: 2-6 weeks
    Lung abscess: 4-6 weeks
    Liver abscess: Minimum of 6 week
    Discitis: 12 weeks

    All prescribed antimicrobials IV/PO must have the indication and a review date or course duration for therapy endorsed on the prescription.

    EFFECTIVE ANTIBIOTIC PRESCRIBING


    Antibiotics are essential to modern medicine and may be life-saving, but their misuse leads to resistance and side effects. All physicians who prescribe antibiotics have a responsibility to their patients and for public health to prescribe optimally:

    Top Ten Tips
    1. Initiate antibiotic treatment immediately in patients with life-threatening infection. Time to first dose of antibiotics is often critical to prevent worsening condition and sometimes death. It is essential that the first dose is given as early as possible, particularly when the patient is unwell enough to warrant intravenous (IV) treatment. Instead of waiting for the next drug round, write the first dose of antibiotics as a Once Only (stat) dose on the front of the Inpatient Prescription Chart (Kardex). Intravenous antibiotics MUST be given within 1 hour of prescribing and oral antibiotics within 2 hours. Failure to comply with this classes as an adverse clinical event according to the Trust Medicines Optimisation Policy (Clin Corp 62) and must be reported on DATIX.
    2. Prescribe in accordance with local policies and guidelines avoiding broad spectrum agents where possible.
    3. Document in clinical notes and on Inpatient Prescription Chart indication(s) for antibiotic prescription and course length to facilitate future management of the patient.
    4. Send appropriate specimens to the microbiology lab, draining pus and removing foreign bodies if indicated.
    5. Use antimicrobial susceptibility data to de-escalate/substitute/add agents and to switch from intravenous to oral therapy.
    6. Prescribe the shortest antibiotic course likely to be effective.
    7. Always select agents to minimise collateral damage (i.e. selection of multiresistant bacteria/Clostridium difficile).
    8. Monitor antibiotic drug levels when relevant (e.g. vancomycin, gentamicin).
    9. Use single dose antibiotic prophylaxis wherever possible.
    10. Consult a Medical Microbiologist if the policy is unhelpful.

    Taken from Royal College of Physicians Healthcare Associated Infections Working Group.

    GENERAL POINTS ON PRESCRIBING


    The purpose of this policy is to provide recommendations on the initial empirical or ‘blind’ therapy based on the likely pathogens involved and local antimicrobial susceptibility data. Doses given are generally those for adults with normal renal and hepatic function. Further details on side effects and contra-indications etc. can be obtained in the British National Formulary.

    These guidelines are to be used alongside current editions of other Trust Antimicrobial Guidelines which apply to special patient groups. These guidelines are:

    • Southport and Ormskirk Hospitals NHS Trust Neonatal and Paediatric Antimicrobial Guidelines
    • Southport and Ormskirk Hospitals NHS Trust Obstetrics and Gynaecology Antimicrobial Guidelines

    Bacteriological specimens e.g. urine, sputum, pus etc should be taken before giving an antibiotic. Blood cultures should be taken in all cases of serious infection. In general if IV antibiotic treatment is deemed necessary, then blood cultures should be taken. Results of cultures must be checked as it may be necessary to alter antibiotic therapy on the basis of culture and sensitivity results.

    START SMART THEN FOCUS


    The Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI) Antimicrobial Stewardship Guidance recommends the following approach for the initiation and ongoing review of empirical antibiotic treatment:

    START SMART
    • Do not start antibiotics in the absence of clinical evidence of bacterial infection.
    • If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with life threatening infections. Always space antibiotic doses evenly through the 24 hour period. Avoid inappropriate use of broad-spectrum antibiotics.
    • Document on drug chart and in medical notes: clinical indication, duration or review date, route and dose. Antibiotics in hospitals are often continued unnecessarily because clinicians caring for the patient do not have information indicating why the antibiotics were initially commenced and how long they were planned to be continued. This problem is compounded where primary responsibility for patient care is frequently transferred from one clinician to another. Ensuring that all antibiotic prescriptions are always accompanied by an indication and a clear duration or review date will help clinicians change or stop therapy when appropriate.
    • Obtain Cultures First - knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens and stopping antibiotics when cultures suggest an infection is unlikely.
    • Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have been shown to be effective. Critical to this advice is that the single dose is administered within the 60 minutes prior to surgical incision or tourniquet inflation to enable peak blood levels to be present at the start of the surgical procedure. A repeat dose of antibiotic prophylaxis is required for prolonged procedures and where there is significant blood loss. A treatment course of antibiotics may also need to be given (in addition to appropriate prophylaxis) in cases of dirty surgery or infected wounds. The appropriate use and choice of antibiotics should be discussed with a Medical Microbiologist for each case.

    THEN FOCUS
    Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action - the “Antimicrobial Prescribing Decision”
    Antibiotics are generally started before a patient's full clinical picture is known. By 48 hours, when additional information is available (including microbiology, radiographic and clinical information) it is important for clinicians to re-evaluate why the therapy was initiated in the first place and to gather all available evidence on whether there should be changes to the therapy.

    The 5 antimicrobial prescribing decision options are:
    1. Stop antibiotics if there is no evidence of infection
    2. Switch antibiotics from intravenous to oral
    3. Change antibiotics – ideally to a narrower spectrum – or broader if required
    4. Continue and review again at 72 hours
    5. Outpatient Parenteral Antibiotic Therapy (OPAT).

    It is essential that the review and subsequent prescribing decision is clearly documented in the medical notes. A clear management plan should be documented if a prolonged course of antibiotics is contemplated.

    IV TO ORAL SWITCH (IVOST)


    Advantages
    • Reduction in likelihood of hospital acquired bacteraemia and infected IV lines.
    • Improved patient comfort and possible earlier discharge.
    • Saves nursing and medical time.
    • Reduces costs.

    Serious infections require intravenous antibiotics initially. Unless the patient is suffering from a deep-seated/high risk infection (see below) the treatment should usually be changed to oral after 48 hours. Patients meeting the following criteria should be reviewed for IVOST:
    • Received >24 hours of IV therapy
    • Clinical condition improving and patient haemodynamically stable
    • Patient afebrile for >24 hours
    • Trend towards normalisation of CRP and WCC
    • Able to tolerate oral route of administration
    • Functioning gastrointestinal tract
    • Appropriate oral antimicrobial option is available
    • No haematological malignancy or neutropenia
    • No evidence of deep-seated infection that requires prolonged IV treatment (see examples below):

    High risk/deep-seated infections which require IV treatment for longer than 48 hours:
    • Osteomyelitis
    • Septic arthritis
    • Mediastinitis
    • Staphylococcus aureus (including MRSA) bacteraemia
    • Necrotising fasciitis
    • Deep abscesses e.g. lung abscess or liver abscess
    • Empyema
    • Cavitating pneumonia
    • Legionella pneumonia
    • Cystic fibrosis exacerbation
    • Endocarditis or intravascular infection
    • Infected implants/prosthetics e.g. joint replacement
    • CNS infection e.g. meningitis/brain abscess/encephalitis
    • Immunocompromised patient e.g. chemotherapy induced neutropenia
    NB. This list is not exclusive


    For these infections duration of therapy can be discussed with Medical Microbiology.

    When reviewing antimicrobial treatment it is especially important to review culture and sensitivity results when available. It is acceptable to change to a different antibiotic if the infecting organism is sensitive e.g. IV cefUROXime may be changed to oral co-amoxiclav, IV cefTAZidime may be changed to oral ciprofloxacin etc.

    Rational oral alternatives to some commonly used empirical IV antibiotic agents – Note that isolate sensitivities must always be considered

    IV Oral
       
    Amoxicillin 500mg-1g 8 hourly Amoxicillin 500mg-1g 8 hourly
    CefUROXime 1.5g 8 hourly AND metronidazole 500mg 8 hourly CefaCLOR 500mg 8 hourly
    AND
    metronidazole 400mg 8 hourly
    OR
    Co-Amoxiclav 625mg 8 hourly (if not penicillin allergic)
    CefUROXime 1.5g 8 hourly CefaCLOR 500mg 8 hourly
    Clarithromycin 500mg 12 hourly Clarithromycin 500mg 12 hourly
    Flucloxacillin 1-2g 6 hourly Flucloxacillin 1g 6 hourly
    Clindamycin 600mg-1.2g 6 hourly Clindamycin 300-450mg 6 hourly
    Piperacillin-tazobactam
    Meropenem
    Vancomycin
    No clear oral alternative.

    Review positive Microbiology results for sensitivities and refer to guidance for oral step down under individual infections. If further advice is required, discuss with microbiology.
    IV vancomycin must NOT be switched to oral vancomycin.

    OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT)


    A multidisciplinary team approach for the management of medically stable patients requiring IV antibiotic therapy. OPAT provides both an efficacious and cost effective treatment option for patients needing long and short term IV antibiotics.

    An effective community intravenous antibiotic therapy service will promote:
    • Better quality of life for patients
    • Reduced length of hospital stay
    • Potential reduced health care related infections

    There are two community IV antibiotics/OPAT teams working in this locality;
    • The Sefton community IV team - broadly covering patients registered with a Southport or Formby GP surgery.
    • The Community Emergency Response (CERT) Team - broadly covering patients registered with a West Lancashire GP surgery (e.g. Ormskirk, Skelmersdale, Burscough)

    See the Southport and Ormskirk Hospitals NHS Trust OPAT policy (Clin Corp 93) for specific requirements. All patients must be individually discussed with the appropriate community IV team when planning for OPAT.

    PROCESS FOR REFERRING PATIENTS FOR OPAT


    1. Contact the appropriate community IV team for the patient’s locality to discuss availability and eligibility of the patient for OPAT.
    2. If the patient can be accepted, Doctors caring for patient must complete referral documentation according to the Trust OPAT policy (Clin Corp 93).
    3. Not all antibiotic regimens are suitable for OPAT (e.g. 6 hourly IV flucloxacillin). The antibiotic treatment should be discussed with Medical Microbiology to ensure a regimen suitable for OPAT and suitable for the infection and pathogen being treated.
    4. Referral documentation must be faxed to OPAT team and clinical team must document that the referral has been accepted in the patient’s medical notes.
    5. Discharge prescriptions (e-discharge) must be completed in accordance with referral documentation and include all IV drugs, diluents and flushes. The planned duration of antibiotic treatment must be specified on the TTO.
    6. Patients on OPAT remain the responsibility of the discharging consultant and the patient must be reviewed at least weekly. This can be done by the patient attending an outpatient clinic or failing that by attending the ward.
    7. Pharmacy will supply sufficient OPAT medication on discharge to last until the patient’s first hospital review. When the patient attends hospital for their review they should collect their next weeks supply from pharmacy and so on. Pharmacy will continue to dispense weekly supplies until the end of the planned duration on the TTO unless advised the patient has stopped treatment sooner or has been re-admitted.
    8. If the treatment course is required to extend beyond the duration specified on the TTO then a further prescription will be required for the ongoing supply (including diluents, flushes etc.) Also the community IV team must be informed that the course is to be extended beyond the initial planned duration.
    Please note that OPAT referrals cannot be made out of hours.

    ESSENTIAL INFORMATION ABOUT DISCHARGE MEDICATION FOR PATIENTS ON OPAT
    In order to avoid delayed discharges, the ward clinical team must plan discharges on OPAT in a timely manner as these TTOs can be very large (includes drugs, flushes, diluents and additional therapies) and may take pharmacy a significant length of time to prepare. TTOs for OPAT prescriptions must be in pharmacy no later than 3pm and will not be processed outside of normal pharmacy working hours. Pharmacy will only supply sufficient medication on discharge to last until the patients first review (weekly clinical reviews are a requirement for OPAT patients). Patients must be informed that they have to attend the inpatient pharmacy (NOT Rowlands) to collect their weekly supplies when they come in for their weekly reviews.

    For further information or queries contact Antibiotic Pharmacist(during normal working hours only: 0830–1700 Monday to Friday).

    POINTS ON SPECIFIC ANTIBIOTICS



    Ampicillin/amoxicillin
    Intravenous or oral preparations: Use amoxicillin. Organisms sensitive to ampicillin are sensitive to amoxicillin

    CefUROXime
    Please note that oral cefUROXime is not equivalent to intravenous cefUROXime. The oral dose is much lower and poorly absorbed. Oral cefUROXime is not stocked. When switching to oral antibiotics, refer to sensitivity of infecting organism.

    Ciprofloxacin
    Oral ciprofloxacin has similar bioavailability to IV therefore IV should only be used where the oral route is unavailable. Ciprofloxacin may lower the seizure threshold and may precipitate seizures in epilepsy.

    Clarithromycin/erythromycin (macrolide antibiotics)
    IV or oral clarithromycin should be used instead of erythromycin in most instances (see exceptions below). If an organism is sensitive to erythromycin, it will also be sensitive to clarithromycin. Use oral route where possible as oral bioavailability is good and the IV form is highly thrombophlebitic.

    Use erythromycin in: Pregnant women, for long-term prophylaxis in splenectomised patients who are allergic to penicillin and patients on another drug that interacts with clarithromycin but not erythromycin (e.g. ticagrelor).

    Co-trimoxazole
    Can cause serious side effects e.g. blood dyscrasias and severe skin reactions. Its use should be avoided unless essential e.g. pneumocystis pneumonia, Stenotrophomonas maltophilia infection. Co-trimoxazole is contraindicated in patients on methotrexate.

    Doxycycline
    Advise patient to avoid direct sunlight where possible and to wear high factor sunblock when out in the sun. Doxycycline should be swallowed with plenty of water and the patient should be advised to remain sitting or standing upright for an hour after taking it. Doxycycline dose should be administered at least 2 hours apart from any calcium supplements and/or antacids as these will interfere with absorption. In many cases this Guideline advises a high dose doxycycline regimen (200mg 12 hourly for two doses then 200mg once daily). This regimen is to ensure rapid loading of doxycycline in hospitalised patients with more severe infections. For the same indications it is acceptable for the emergency department to prescribe the dosing regimen typically used in primary care (200mg on first day then 100mg daily) for patients with mild infection who are not for admission. The doxycycline doses advised for treatment of gentio-urinary infection (e.g. pelvic inflammatory disease) must be adhered to however.

    Gentamicin
    Dosing must be according to patient’s weight and renal function and levels must be monitored. Gentamicin can be nephrotoxic and ototoxic and patients should be advised to report any hearing or balance issues. Contact Medicines Information or Antibiotic Pharmacist or Ward Clinical Pharmacist (or if out of hours, on-call Pharmacist via switchboard) for further advice if needed.

    Linezolid
    Linezolid is a weak monoamine oxidase inhibit